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Re: Patella Tendonosis or 'Something Else'?
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Re: Patella Tendonosis or 'Something Else'? - July 18, 2006 2:10:00 PM
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steve
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Ginger,
I'm not suggesting that centrally based treatment isn't effective with a specific subgroup of patients (I believe it is), I am questioning the theoretical basis upon which you have derived this model.
Your response is similar to what I see on late night infomercials with testimonial based evidence used to sell products as miracle cures. We have moved beyond this from both an ethical and scientific standpoint; it is no longer enough to say it works because I see it work everyday and on this basis disregard significant scientific evidence to the contrary.
caveat emptor
Steve
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Re: Patella Tendonosis or 'Something Else'? - July 18, 2006 2:14:00 PM
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ginger
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From: Melbourne Victoria
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The difference steve is I'm a colleague trying to help you , not a salesman trying to sell you a product.
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Re: Patella Tendonosis or 'Something Else'? - July 18, 2006 6:46:00 PM
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nari
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Steve
I agree that mobilising, say,L4(R)facet does have a bowstring effect, and other joints can be affected; palpation is intra- and interunreliable.
However, this does not mean the method is useless to promote.
Given that the effect of spronging on the area is neuromodulatory (there can be no other rationale) then it may not matter much whether it is L3 or L5. Movement --> pain resolution in very crude terms, and this can be achieved in many ways. As long as the principles of neuroscience are understood, and specifically the recently developed physiology of pain perception and experience - it is evidence enough. This is something RCTs, for instance, cannot really determine; unless done with fMRI so the lit brain areas are observed.
By treating only the periphery, the perceived site of pain, results can be good, but slow and probably less reliable from patient to patient, depending on predictibility factors and whatever else is deemed relevant.
Nari
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Re: Patella Tendonosis or 'Something Else'? - July 18, 2006 6:57:00 PM
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ginger
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Nari it most cetainly does matter which joint one mobilises, what is more there most cetainly is another and better explanation then the neuromodulatory one you suggest. The important thing perhaps for now may be that central issues we agree on , but to muddy this gentlemans waters with the idea that introducing joint movements willy nilly without a meaningful corespondence to neuraly related structures is improper.
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The Grand Pediculator
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Re: Patella Tendonosis or 'Something Else'? - July 19, 2006 1:35:00 AM
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Sebastian Asselbergs
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Nice Ginger. Now please tell me without getting into insulting little asides about others' practices and educational/experience levels, how do propose to treat the injured meniscus I spoke about in my post of July 18?
Lateral knee pain.
We have established it's a human patient, conscious.
You suggest to check spinal and central issues first.
OK.
Sproing (lovely word, nari) the L3 - specifically.
Will I see the immediate results you claim with this approach?
Will I see the swelling disappear?
Will this fix the meniscal damage?
I won't have to tell the patient about how to care for the injured area?
I won't have to refer the patient?
As many here know, I do entertain the notion of the importance of central involvement - very seriously. For a few years now.
The way you bring it though, is soooo simplistic and exclusionary of any other facets - it makes me wonder whether you hagve gotten stuck in one rut. It looks as if sproinging the spine is all you do, for whatever the patient presents with. Easy, look for the related spinal segment, mobilise/sproing - and bingo - health. I don't want to believe that this is the extent of your practice.....but it seem like you only have one tool - a hammer. And darn it if those patients don't all look like nails...
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Re: Patella Tendonosis or 'Something Else'? - July 19, 2006 1:41:00 AM
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Sebastian Asselbergs
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Oh BTW, how is ANYTHING in the body "without a meaningful corespondence to neuraly related structures" - for someone with such focus on neural origins, you should know that everything is related neurally in the human body. Or do you propose that "only" sproings on L3 will affect the L3 segment? Please. A bit deeper look in neurobiology and neurophysiology shows many variations of ascending and descending paraspinal multi-segmental connections, not to mention the all-important ..wait for it....brain...
All kidding aside, IF you are using multiple approaches to your patients' problems, I stand corrected: but you haven't exactly made that clear in your persistent focus HERE on the sproinging.
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Re: Patella Tendonosis or 'Something Else'? - July 19, 2006 11:38:00 AM
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nari
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Ginger, hey,you're spronging at some windmills here...I did not imply (did I?)that if you want to treat a knee, then mobilising any old level would do. Let's say you have decided to mobilise L3, for some distal area. With your technique, specifically on L3 facet, the effect will rattle up and down to other levels as well. That's all I'm saying. It is no doubt more beneficial to aim specifically, but the passive movement will not be specific ONLY to one joint....
As you may well know, the Australian chiros talk a lot about pain and treatment effects 'rattling' up and down the spine and seem to have recognised years ago that a specific manipulation has generalised effects, just as the pain experience 'shifts' around.
One really can't sprong on one spot, particularly in the spine, without wide CNS effect. That's what I reckon.
Nari
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Re: Patella Tendonosis or 'Something Else'? - July 19, 2006 1:48:00 PM
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ginger
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Nari
Yes it is clearer to me now that your line "it may not much matter wether it is L3 or L5", was not so much a suggestion for a non specific approach , but a recognition that joint behaviour , both in terms of improvements by attention , and losses of movement due to protective responses, are seen to affect adjacent joints. My attention was sprung at the last moment of my day by what looked like a vastly different interpretation than I'd come to expect .
My apologies as I ought to have sought clarification before launching my ship.
The specifics of attention with mobilisation as you point out have a bearing on the likelihood of success with referred events no doubt. While accepting that in the general sense, any protective response with resultant inflammatory events occuring in the spine , seems to have a negative effect , or rather a sensitising effect on the rest.
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The Grand Pediculator
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Re: Patella Tendonosis or 'Something Else'? - July 19, 2006 2:03:00 PM
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ginger
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Sebastian, forgive me but I have been caught up in a new position and have even less time to correspond.
Were your patient to have lateral knee pain than it is more likely to be an L4 related issue , if it is at all. There is no doubt Seb , meniscal injuries do occur, along with a host of others. The point I make is that where no injury ( moment of inpact etc) has a meaningful role in patients' history, than it is appropriate to explore the possibility of referred events . By doing so it may be revealed that the swelling, pain and dysfunction are all a product of a neural inflammatory event related to a spinal facet joint or two. Refferd pain/dysfunction is far more common than many are led to believe. Were you to attempt to "prove" the presence of referred events by attempting to reproduce them, in most cases you would fail and go on to asssume none were present.
I contend that a better way is to
a. first be guided by a relevant hx.Brief check of complained of structure.
b. then check the relevant facet level for specific hypomobility/joint tenderness.
c. go on to trest that facet joint with Continuous mobs , PROVIDED that the signs to do so are present.
d. check for changes at the complained of joint/structure.
Back to you in a while.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Patella Tendonosis or 'Something Else'? - July 19, 2006 2:37:00 PM
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ginger
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By this method it will become clear that a great many "mystery" and difficult problems are solved. More to the point , will clearly indicate that many features of the panoply of musculoskeletal pain/dysfunction issues that come your way are best treated at the spine first than to assume a focal injury where no history specific to that exists.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Patella Tendonosis or 'Something Else'? - July 19, 2006 3:30:00 PM
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nari
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Pete,
What with diversionary asides on the virtues of clearing the spinal structures, how are you going?
If you are still around, wondering about the differences between the US and Australian approaches to pain, this is an example of differences amongst physiotherapy clinical cultures.
If you can think of no reason why your knee is plainly complaining (sic), then a spinal approach is likely to be the most appropriate. Ginger would mobilise the spinal segment/s and I would use neurodynamics. Both would most likely give positive responses, but difficult to specify online without assessment.
Nari
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Re: Patella Tendonosis or 'Something Else'? - July 20, 2006 1:39:00 AM
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Pete.
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Hi Nari
Yes, I'm still around - I check out the forum every day, but I wanted to hold off from posting until after my appointment with the Orthopaedic surgeon (this morning).
To update:
(1) I went to see my GP about the night pain and the fact that paracetomol/codeine wasn't making any difference. He put me on a low dose of amitrypiline, which so far has worked well - much reduced pain and sleeping much better.
(2) The Orthopaedic surgeon I saw this morning was adamant that there is no cartilage damage. His diagnosis was 'Anterior Knee Pain', which he defined as irritation/wearing of the bone surface underlying the cartilage. His only concern was the night pain, which he said was not typical of this condition. He wants me to hook up with a physio for a 3 month conservative programme then if things aren't improving to go back and book an MRI. He thinks my patella tracking looks OK.
So, my questions:
(1) What conservative programme would you guys advocate for Anterior Knee pain? I remember that Duffy recommended a 'Shock and Awe' approach - I'd be particularly interested in this especially as I no one that I have consulted has been able to pinpoint a particular structural or biomechanical problem.
(2) Any suggestions on how I might track down (in the UK) an Aussie trained physio who can do passive mobilisations of my relevant spine joints? I'm very open to trying this approach, reason being that I can see a clear imbalance in both firing and size between my Vastus Lateralis and VMO, and I'm wondering if this is caused by some kind of nerve problem.
Thanks in advance for any suggestions.
Pete
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Re: Patella Tendonosis or 'Something Else'? - July 20, 2006 1:53:00 AM
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Sebastian Asselbergs
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Ginger, now that sounds more like a common practice here. "where no injury ( moment of inpact etc) has a meaningful role in patients' history," is what we were taught in school; NOW we check the spine and its motion at the segmentally related levels. Since then, I have learned to look at peripheral neural tissues as well, and now am looking even higher in these cases....
I may have sounded cranky, but I felt that it sounded as if you were deliberately overlooking any structural pathology. Thanks for the clarification.
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Re: Patella Tendonosis or 'Something Else'? - July 20, 2006 2:00:00 AM
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Sebastian Asselbergs
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Pete, I am quite sure now that it may indeed be the best for you to find a PT with a strong focus on the neural tissues with manual techniques - it is obvious that the orthopod really doesn't know what is going on and thus refers to "3-month" conservative PT program....whatever that means (he likely thinks: modalities and exercise...).
Your question #2 is rather telling - yes, I would suspect that your nervous system is heavily involved as a target-tissue for treatment.
To find a good PT for that? Can't help you with that in the UK....
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Re: Patella Tendonosis or 'Something Else'? - July 20, 2006 1:17:00 PM
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ginger
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Pete there are several physiotherapy associations in the UK. each of which will have a register of local physios . It is possible they may also know of the particular skills and interests of these people, possibly even where they are trained. Worth a look there as first base. The Chartered Society of Physiotherapists looks after those who are government licenced, so probably the best , certainly the biggest.
All the best ( they hire chain saws in the UK don't they?)
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Patella Tendonosis or 'Something Else'? - July 21, 2006 11:54:00 PM
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Pete.
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Thanks, Sebastian and Ginger. I've Googled for a physio who does passive mobilisations and found one in London (long way from where I live). I'll try and get an appointment with them. From what you've said, it sounds as though I'll know after 1 session whether that approach is making a real difference.
In the meantime, I'm very open to pointers on comprehensive 'shock and awe' rehab programmes for anterior knee pain.
Cheers
Pete
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Re: Patella Tendonosis or 'Something Else'? - August 14, 2006 7:36:00 PM
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Amy Bennett
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Pete -
Sarah Counsell has postprofessional training from Curtin University in Perth, Western AU. She is now in Cardiff. You can e-mail her at: sac@macace.net
Or try Linda Exelby in Hitchen. Email: Lexelby@compuserve.com
Just explain your symptoms, any history of injury, and what has been done so far. Good luck!
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Re: Patella Tendonosis or 'Something Else'? - August 14, 2006 7:40:00 PM
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Amy Bennett
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Pete -
Sarah Counsell has postprofessional training from Curtin University in Perth, Western AU. She is now in Cardiff. You can e-mail her at: sac@macace.net
Or try Linda Exelby in Hitchen. Email: Lexelby@compuserve.com
Just explain your symptoms, any history of injury, and what has been done so far. Good luck!
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Re: Patella Tendonosis or 'Something Else'? - August 15, 2006 12:32:00 AM
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Pete.
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Thanks Amy - I'll give that a try.
Best wishes
Pete
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