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Re: musculoskeletal myths#7 pubic symphesitis
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Re: musculoskeletal myths#7 pubic symphesitis - August 25, 2005 2:21:00 PM
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ginger
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Joined: February 26, 2005
From: Melbourne Victoria
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Hi all, a little homily to start the day, or at least that is what I'm doing. Looking forward to some unseasonal warmth over the coming weekend, 23 in Melbourne this weekend, yahoo!, now , where was I , oh yes, a homily.
I grew up as a farmers son on a property in south ausralia, Olives, grapes, cattle, most of the local farmers had a combination of crops or fruits to take care of. Around when I was twelve there was a high school teacher who taught agricultural science , nice guy , drank a bit as I recall. Anyhow he bought an adjoining property and proceeded to install all manner of high tech ( for the time ) gear. He invested in testing equipment to monitor water , soil temperature, Ph.,and various other important nutrient values. He put in irrigation, hired department of primary industry folks to come out and inspect and report, made his decisions on the basis of a wealth of science and clued himself up no end on the modern business of farming to the nth degree.
Nice bloke, had a big family, went to church at the local where my mum went. I remember feeling a bit miffed when he went sold up and left as I was a bit keen on his daughter. Turned out he'd neglected the obvious. Hadn't thought about the possibility of a little extra rain when he diverted the creek to feed his irrigation . A flash flood wiped out the whole lot in an afternoon. Poor silly bugger, My dad had been telling him for ages the creek rises every so often. Ah well , you can't beat science for numbers, but jeez loueeze, where's the wisdom when it all fails because you didn't check the obvious first.
nil desperandum.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: musculoskeletal myths#7 pubic symphesitis - August 25, 2005 5:01:00 PM
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chiroortho
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[QUOTE]23 in Melbourne this weekend, yahoo[/QUOTE]I live in Melbourne, Florida Ginger and our temp will probably be in the 90* range this weekend.
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Re: musculoskeletal myths#7 pubic symphesitis - August 25, 2005 5:50:00 PM
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nari
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From: Australia
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But 23C in Melbourne (Oz) is a bit scary - this is the end of our winter!!
32C sounds about right for Florida's summer??
Nari
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Re: musculoskeletal myths#7 pubic symphesitis - August 26, 2005 7:00:00 AM
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JLS_PT_OCS
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Oh, Nari, you're assuming most of us Americans can remember the conversion equation?
You give us too much credit.
I can never remember if it's 9/5 or 5/9, etc...
J
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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: musculoskeletal myths#7 pubic symphesitis - August 26, 2005 7:32:00 AM
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Yogi
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SJ, I wouldn't worry overmuch about findings for court. Opposing counsels always have one psychologist to say one thing, and the other side has one to say the opposite. Who knows who's right? Just get a believable distinguished-looking Doc (Top of the food chain, you know) to lie convincingly, er, I mean testify convincingly that you knew what you were doing.
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Re: musculoskeletal myths#7 pubic symphesitis - August 26, 2005 9:46:00 AM
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srcase
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From: Michigan
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Just to play devil's advocate, if the patients Ginger sees are getting better as quickly as he claims they are, I'd bet they aren't concerned with how reliable his examination procedures are. Plus, I just liked the farm story because I grew up on a farm too. I think sometimes we do forget to see the forest for the trees.
Sarah
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Re: musculoskeletal myths#7 pubic symphesitis - August 28, 2005 2:44:00 PM
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ginger
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From: Melbourne Victoria
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hey Sara C. these city folks are slow learners sometimes aren't they, where was your farm?
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The Grand Pediculator
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Re: musculoskeletal myths#7 pubic symphesitis - August 28, 2005 4:13:00 PM
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ginger
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From: Melbourne Victoria
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To SJBird, in answer to your questions earlier, how focused on the spine, or perhaps should read why ?, not because I started out with any preconcieved notions about spines being so important, simply that as I went along solving problems , it became increasingly clear that some of the central notions I had been taught didn't hold up. Listed then in no order of importance. 1. That "clearing tests" for peripheral anomalies and pain were frought with false positives and negatives. So I stopped doing them. 2. That the notion that a referred pain had to be reproduced by acting on a central structure to " prove" it was referred, was even less likely to be a valuable guide than the "clearing test".3. That in the process of engaging and mobilising facet joints there is an increasing likelihood that as I continue to mobilise, tone reduces around the joint, this then is the reason for mobilising. When a state of reduced tone of paravertebral muscles is reached, there will be a loss of inflammatory events of those facet joints over a 24 hour period. These changes are ,for the most part , permanent.Further loss of tone with following treatments (mobilisation ) will see a further loss as above, to pain and dysfunction. I simply observed that a long list of apparently local pain events , would dissapear , along with the tightness and pain associated with the neurologically relevant joints.A short list of these musculoskeletal disorders have been posted here entitled myths.
So to reiterate, how would I prove that the periphery was "cleared", easy, mobilise the relevant facet joint and watch as the problem goes away, seems easy enough to me.
What time frame post onset, any. All. acute, sub acute, chronic, acute on chronic, you name it.
The important subject of how to mobilise could well shape the attitudes of the nay sayers , There is no mathematical equation to suit facet joint mobilising. It is necessary to establish a ryhthm and real time sense of change as it happens while pursuing facet joint movement. It is not necessary or usefull to push then with any great force mostly. Just that as movement occurs, that therapist remain alert to change in tone. This will be seen to associate with reported pain ( of the facet joint when passively moved), with dcreases in pain as tone decreases. Most of my students and mentees can only mobilise for around five minutes when they begin, it may take four or five weeks to be able to continulously mobilise for twent to thirty minutes. My hands don't feel fatigue any more, just through practice. If I remember rightly it may have taken me a few months of steady application to the continuous method before I felt truly comfortable. This is so for my students too.
The continuous mobilisation method is a sensitive engagement between therapist and facet joint activity.
Am I serious about this material, or do you think I'm just throwing it out to stimulate debate?. Thsi is my lifes work Birdy, It consumes my time energy and focus for year after year. I find myself at the happy position of being able to stand at the end of the line as it were, with a method that works time and again . It is learnable, doable and consistant. This method and the assertions I have made in these posts are the non diluted straighforward jug of whiskey babe. Take off the mental straighjacket and check it out for yourself. You are welcome to disagree, to offer your own opinion, to say no thanks, whatever, just read and think. Hopefully I'll strike a chord in the minds of those who are ready.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: musculoskeletal myths#7 pubic symphesitis - August 28, 2005 5:38:00 PM
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SJBird55
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hmmm, go into a bit of detail with #2...
There seems to be more and more published research that during the examination/assessment process that determining the structure potentially involved in the patient's current complaint has a higher probability of being recognized via the postiveness of say 3 out of 5 tests or measures (just an example). Some of the tests seem to be pain provocation tests, for example. So, how is information like that not valuable?
And [QUOTE]So to reiterate, how would I prove that the periphery was "cleared", easy, mobilise the relevant facet joint and watch as the problem goes away, seems easy enough to me.
[/QUOTE]does that mean that you can do something that is the opposite of a pain provocation test? If the person is in pain, you can get an immediate result of substantially reduced pain? But, then what do you do with the patient that comes in with a complaint of pain that isn't present during your examination process?
And, then, I hate to be picky, but could you define "mobilization." What does that mean to you... since you're in Australia, I really don't know if what I think of as mobilization is the same as what you think of as mobilization. I know in my area that mobilization the way I'm thinking of it isn't provided for 20-30 minutes. (And I will admit that I do think that third party payers and their reimbursement rules could be and probably is a driving force in how we in the States provide services/care.)
In your knee example, I honestly don't quite agree that the spine is the culprit all the time. I think of people at a higher level of function and Chris Powers' stuff really makes sense and I have had some decent results with treatments by observing athletes and their movement patterns - in particular females. So, I really don't see how consistent and permanent results can be obtained by mobilizing the spine with that particular group of folks. For folks who are predominantly sedentary, maybe the spine is a factor, I don't know.
I read and I think... but then that generally leads to more questions.
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Re: musculoskeletal myths#7 pubic symphesitis - August 28, 2005 7:17:00 PM
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ginger
Posts: 647
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From: Melbourne Victoria
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Ok SJ, more questions, more answers. lets start with.
"does that mean that you can do something that is the opposite of a pain provocation test? If the person is in pain, you can get an immediate result of substantially reduced pain? "
A.Exactly.
"then what do you do with the patient that comes in with a complaint of pain that isn't present during your examination process?"
A. examine the relevant spinal segment for palpable tenderness/hypomobility of the facet joint(s). If sore to probing with your thumb, mobilise till palpable tenderness is substantially reduced or you run out of treatment time.Examine the relevant dura, if tight( slump), stretch. Ballistic is best. Expect change either immediately if pain was present, or over 24 to 48 hours if fatigue etc is the factor inducing pain.
"could you define "mobilization"
A. The continuous method of spinal facet joint mobilisation. Is an attempt by efforts directed at facet joints, either from a post/ant. or a ant/post ( in the case of cervical ) direction , using the thumb ( other fingers and even implements have been tried but are nowhere near as useful), through a range producing pain at that joint. By a continuous feedback loop provided to the therapist, by an appreciation of the resistance offered to the therapist's thumb, of tonal changes attendant to that joint, of paravertebral muscle. Physiologically normal joints will respond within a 30 to 60 second time period, with a lowering of muscle tone. Further reductions in tone may be continuously felt for periods even up to twenty minutes( in extreme cases of irritability). As the tone change is noticed, the pain associated with passive facet joint mobilisation decreases. At this point it is possible to observe two things. That the normal functional active movements are restored to the facet joint. Also that any supposed or suspected referred pain or altered sensation ( include here altered recruitment pattern such as for VMO )is revealed as such by immediately improving. This process may take from 5 to 40 minutes . NB This is NOT the process as taught ala Maitland etc. which seems to rely on a model entirely different to my own.
"In your knee example, I honestly don't quite agree that the spine is the culprit all the time."
A . have you tried it? how about the next patello/femoral patient you see you examine L3 on the side of the problem. is it painfull with mobs?, then go for it, spend ten minutes at that joint, watch for the signs as above, Check recruitment patterns , patella pain and function before and after, surprise yourself.Be fair , be thorough, keep an open mind, who knows, this could be the break through you have been looking for ( it is , but then I'd sound pompously overconfident )
Have a great evening SJ I look forward to your further comments.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: musculoskeletal myths#7 pubic symphesitis - August 28, 2005 10:52:00 PM
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ginger
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From: Melbourne Victoria
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oops , I've left a line out from the discourse on mobilisation
Please insert after
through a range producing pain at that joint.
To alter the attendant muscle tone around those joints, by so doing restore normal pain free movements. This leads to a loss of the inflammatory events of joints and associated neural structures .
Sorry bout that, these fancy machines sure to take some wrassling to get em to say what I mean.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: musculoskeletal myths#7 pubic symphesitis - August 29, 2005 1:37:00 AM
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SJBird55
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Technically... you are doing a pain provocation test at the lumbar level. You aren't looking for a referred pain kind of pattern though from what you just typed - you are looking for pain at some lumbar level, correct?
So, what do you do if someone comes in and has no palpable tenderness/hypomobility anywhere along the spine?
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Re: musculoskeletal myths#7 pubic symphesitis - August 29, 2005 2:33:00 PM
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ginger
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From: Melbourne Victoria
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then it is safe to assume there is no referred event and proceed to treat at the site of pain. Provided that a THOROUGH exam of facet joints has been done , along with relevant dural tension tests, I consider this a clearing of the most likely first, moving to the less likely , that being , that there is no involvement of the spine.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: musculoskeletal myths#7 pubic symphesitis - August 29, 2005 4:07:00 PM
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srcase
Posts: 551
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From: Michigan
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ginger,
Are you doing a unilateral facet joint mobilization or just a gross mobilization? Have you considered that you are mobilizing much more than the facet joint?? You mention referred pain, but can a facet really refer pain the way you describe, or is it really the neurological tissue that you are affecting?? I guess I'm wondering why you keep mentioning facets when you are mobilizing the spine and all of it's constituent parts at the level of appliction and a few levels above and below (depending on how much force is applied).
Sarah
P.S. the farm was in Michigan
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Re: musculoskeletal myths#7 pubic symphesitis - August 29, 2005 5:48:00 PM
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ginger
Posts: 647
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From: Melbourne Victoria
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Sara, yes for the majority of treatments I find unilateral mobs the most effective to effect referred events. I do occasionaly peform central mobs in cases of acute pain associated with spasm. Though this is mostly where spinal pain is the complained of feature.
No passive movement is able to obviate the movement of (and likely contributions of) adjacent structures. It really doesn't greatly concern me that this is so, as my focus is on making a difference and fixing the problem, rather than anxieties about the possible contributions of soft tissues adjoining joints. What gives me confidence is results.
I don't speak in riddles here Sara, I'm offering a means of problem solving that goes beyond guess work or meaningful associations between muscles and structures. I'm saying , I hope clearly, that.
Referred pain is way more common from spinal facet joints and nerves than you may have thought. Examine and treat as I suggest and you will find this is so yourself, as well as anyone can without my hands to guide you.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: musculoskeletal myths#7 pubic symphesitis - August 29, 2005 6:28:00 PM
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nari
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Ginger
How does a facet joint 'refer' pain?
Why does reduction of stiffness/malalignment/tenderness in a joint relieve pain? What is your basis for these events?
How would you explain a joint can be stiff and tender and yet not associated with the sensation of pain?
You mobilise a facet joint and the pain goes away.
I know you do not investigate the 'why is it so' world much, but to credit pain relief to a tiny joint which is half a kilometre from, say,calf pain.....come on, friend.
Nari
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Re: musculoskeletal myths#7 pubic symphesitis - August 29, 2005 10:07:00 PM
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ginger
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From: Melbourne Victoria
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gosh Nari, what odd questions from a physio, perhaps a period at the old gray's anatomy would be in order.
Also go over "the physiology of spinal pain , a theoretical model" posted in the open forum weeks ago.
Protective activity at spinal joints is a infinitely variable phenomenon.As tightness and inflammatory effects take hold , there will be a point reached as activity escalates,where pain is felt, before which awareness may be minimal or not at all.
I know I'm meant to feel a surge of warmth when someone calls me friend Nari, somehow I don't feel it when you do, why is that?.
You are welcome to spend time in my practice and view these treatments and their results yourself. Lots of others have. All you need to bring are your disbelief, some scepticism, a healthy dose of willingness to learn and bob's your uncle .
Call me on 0438-464014 . or e-mail at fishergn@hotmail.com
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: musculoskeletal myths#7 pubic symphesitis - August 29, 2005 11:57:00 PM
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nari
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Thanks Ginger for your offer. As you did not answer the questions, even from basics, I will leave it at that. There does not seem much point to continue...
Nari
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Re: musculoskeletal myths#7 pubic symphesitis - August 30, 2005 1:31:00 AM
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SJBird55
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Can I call you? Do you accept collect calls? ;)
So, of all the patients that you treat in a day, what percentage of them have a facet problem? What do you do with the elderly that have osteopenia/osteoporosis or have rotten, degenerated joints? Actually, I'd think they'd be folks with major facet problems, are they?
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Re: musculoskeletal myths#7 pubic symphesitis - August 30, 2005 2:05:00 AM
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Sebastian Asselbergs
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And I have always been interested in the "unilateral" joint mobs we were taught. There is something of a arthrokinematic contradiction here IMO. I challenge anyone to do the unilateral mob WITHOUT moving the contralateral joint....
"Protective activity at spinal joints is a infinitely variable phenomenon." So, if it is infinitely variable, simple joint mobs work across a large variety of permutations? It is starting to look like "I have a hammer - jeez, aren't there a lot of nails..."
The belief of the practitioner in his/her own technique is a not unimportant contributor to the success of that technique - maybe you wan tto consider that. That's why the science and studies NEED to be done for the TECHNIQUE to be validated.
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