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Re: musculoskeletal myths#7 pubic symphesitis
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Re: musculoskeletal myths#7 pubic symphesitis - August 30, 2005 4:41:00 AM
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Diane
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Ginger, have you ever considered the possibility that there is likely a huge degree of neuromodulation taking place in treatment as you have described it? I think that was probably what Nari was alluding to.
I've worked for 35 years, and I never found any clearcut patterns of.. well, anything really... I used to think that it was because I was not observant or retentive enough to be able to spot them. But it turned out, it was because there weren't any that made lasting sense to me when I tried to look at pain using spinal joint referral models. I had much better outcomes using outside in models instead of inside out ones.
Using a neuromodulation model (even before I started calling it that) made a lot more sense. (To me.) In that model, anything can "refer pain" to anything (let's blame the real culprit, the brain), because of how the nervous system is organized, with integrated levels of functioning that includes tissue but is not restricted locally to any particular type of it in any particular location; and there is a time lag between treatment of the nerves or neural tunnels and a change in behavior of the pain pattern, even when ROM and immediate decrease in nocioception is apparent. In the first place you are on skin, first. That's the first layer and the most sensitive, so the brain is tuned to skin and will react to skin and anything touching skin, before it will react to anything under it, and forces that one thinks one is applying in a way that bypasses it. Barrett has a neuromodulatory approach that pretty much stops at the skin. Nari doesn't even go there, she talks to people, educates them, and asks them to practice homework, pure CBT.
I go further than I need to (..and almost completely alone) by factoring in embryologic development, which I learned for fun. Consider that the back is completely covered by an ARM muscle, the latissimus, and a HEAD muscle, the trapezius. No matter what you think you are doing to the "spine" you are going through these two structural entities which feed back through the dorsal cutaneous rami at first of course but also eventually will be relaxed by/connect back through their motor input from the accessory and the cervical spine. The input has to go through the brain for that to happen.. the spine doesn't care.. it does its own thing with the epaxial muscles it forms as it emerges from sclerotomes.
Just to add to the fun, sometimes it's necessary to treat the arm or axilla or medial elbow (i.e. brachial plexus..) before lat can let go. Sometimes it's necessary to treat the inside of the knee or back of the knee or head of fibula or ankle or plantar surface of the foot or front of the hip (lumbosacral plexus) before the lat can let go.
In fact.. OK I'm about to pose a major assertion here.. If you get the lats and traps out of the way through simple neuromodulatory techniques/treatment, (the outer layer) the whole lower spine will start to behave better including the pelvis (lats hook onto pelvis) and the neck (the head is strapped onto the body superficially by the traps.) A lot of the mid spine will start to behave better, because the lats and traps will be more free to operate antagonistically where they overlap there. The shoulder girdle will float instead of being pulled down by lats on one side or both.
The next layer in are the muscles that are diagonal and hook into the ribcage, i.e. all the various serratus's (inferior, superior, anterior..), pecs, outer abs etc. Then there are levator scaps, rhomboids, etc that attach more outer bits of skeleton to the spine at multiple segments. Considering those attachments is important, only because the neural tunnels of the peripheral nerves of the spinal nerves have to get through/around them. Mop them up and suddenly the ribcage is bouncier, straighter, and the neck can sit straight.
Whatever might be left in the neck needing specific attention is usually scalenes or SCM.. bear in mind that when I use the names of muscles I'm not blaming them for causing pain, I'm using them as a map for finding neural tunnels to treat in order to neuromodulate the nerves that live within them.. which when treated result in freedom for the spine to move, elongate, be uninhibited, access all its "facet joint movement" without any problem, by accessing all the available newly uninhibited antigravity musculature/function, and have elastic recoil available to it.
That's my little homegrown model in a nutshell, deinihibit the epaxial (embyologically and evolutionarily oldest group of muscles we have) by neuromodulating away adverse neural tensioning in the outermost layers, and then teach people how to stay that way.
I realize this sounds like heresy to most, but really it's just looking at the body through the wide end of the telescope instead of the narrow end for a change.
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Re: musculoskeletal myths#7 pubic symphesitis - August 30, 2005 2:30:00 PM
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ginger
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SJ , most.
The issue of degenerative change is an interesting one for me. As physios we are often asked to treat the elderly who may have encountered the all too common dismissal from orthodox medicine. "you have arthritis , learn to cope" or "there is nothing anyone can do about your pain, take these drugs". When I worked in an environment where the elderly predominated I would treat them with the same methods I use for the younger patients. In the face of x-ray evidence of severe degenerative change to facet joints and adjacent structures, , the responses to mobilisation were nothing short of amazing for these people. Responses are sometimes slower, but almost always immediately positive , with excellent long term improvements to both localised spinal pain and referred events. Mobilisation is safe and effective across a broad range of age groups and certainly where x-ray evidence suggests degenerative lesions.
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Re: musculoskeletal myths#7 pubic symphesitis - August 30, 2005 3:02:00 PM
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SJBird55
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Which then means that your choice of intervention for decreasing pain does not really work at the joint level, per say. If you know for a fact that the patient has severe degenerative changes and has osteophytes, then you also know that those degenerative changes are not reversible (as of yet, especially with physical therapy intervention)... so, what is your theory as to why your intervention produces results?
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Re: musculoskeletal myths#7 pubic symphesitis - August 30, 2005 4:50:00 PM
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ginger
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Dear Dianne, thanks so much for taking the time to go over your approach for me, I have read your pieces before on meuromodulation, the only difficulty is I'm still
totally at sea with the how, not with the why.
I'll re read this last post of yours again a few more times and attempt what understanding my confused brain allows for now. More on the how would be good.
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Re: musculoskeletal myths#7 pubic symphesitis - August 30, 2005 4:57:00 PM
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ginger
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degenerative changes are not reversible, quite right , just irrelevant. What is important is function. Where protective behaviour is participating in the mix causing pain, I turn my attention to what I CAN make a difference to , that behaviour. In particular the tone increases attendant to facet joints and the consequences , inflammation and pain.
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The Grand Pediculator
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Re: musculoskeletal myths#7 pubic symphesitis - August 31, 2005 2:06:00 AM
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SJBird55
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So, if there is a protective mechanism occurring in the spine around the facet joint area - that can be a plausible occurrence and it could potentially refer pain. I agree with that logic. I can't say I've always agreed with the "inflammation" part of the statement in a chronic situation.
But in the patellar example... you have a patient coming in with patellar pain... the person has no lumbar complaints... you find discomfort or tension at the lumbar level.... you do the mobilization technique.... now, how does the function of the lower extremity change with that treatment? What do you assess in the lower extremity prior to the mobilization techniques to then reassess after the treatment which indicates change?
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Re: musculoskeletal myths#7 pubic symphesitis - August 31, 2005 4:25:00 AM
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Diane
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[QUOTE]More on the how would be good[/QUOTE]The "how" is the same way you do it, Ginger, waiting until change is felt through your hands, til the patient sighs and relaxes, their body widens and flattens on the table, etc. Keeping up a contact until the job is done. That's what struck me abou your approach, is that you do that, and that is what it takes to do neuromodulation. (The part you would be reluctant to let go of, however, is where you think it's necessary to hang out with facet joints to accomplish that, each and every time.. :) )
Agree with you that degenerative changes are largely coincidental, or maybe resultant, rather than causative.
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Re: musculoskeletal myths#7 pubic symphesitis - August 31, 2005 7:05:00 AM
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JLS_PT_OCS
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As an aside, despite the lack of outcomes research to support many of Diane's techniques, the basic science behind them is substantial, and in fact evidentiary support can even be found in other systems that seek to work through skin contact, such as Barrett Dorko's work or acupuncture.
J
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"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 31, 2005 7:34:00 AM
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Diane
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Thank you for that Jason.
I did a bit of posting this morning on NOI about this. I found myself inexplicably irritated by the zombie-like ritualized insistance I've noted among my peers, i.e., that which I have come to refer to as "Mobilipulator" techniques are so widely assumed to be effective and exclusively bowed down to as the be-all and end-all of spinal treatment. (Ginger, Jason, this is nothing personal about you.)
I've brought most of that post here, because I think it applies. The emphasis on this buried part of the body (spinal column) ranges from it being the source of all dysfunction (historical chiro) to it being the 'promised land' of all correction of dysfunction (chiro, PT, osteo). Same thing, really, I think..
I started thinking about the homunculi and how they really don't contain much representation of the spine, either motor or sensory. It would seem, therefore, to be a part beyond cortical control. So I thought what that might mean. And this is the sequence of thought that resulted:
1. Spines were around long before brains became fluffy. Our fish ancestors took them and became vertebrates. Fish are not noted for braininess. Fish use/used spines for their total sum of locomotion. (Fins are just stabilizers, not movers.)
2. Spines form from sclerotomes; the vertebral bones and muscles that relate the bones to one another all form at the same time, from the same substance, cranial to caudal, and require little or no hard drive (brain) to run.
3. The muscles that work the back are termed "epaxial" in embryologic terms, to make a distinction between them and all the other muscles in the body, including all the ones that came along later and covered up the epaxial ones, called "hypaxial." (E.g., lats, traps, rhomboids, psoas, limb muscles, abs, etc.) Epaxials are triggered by different genes than hypaxial muscular development.
3. The epaxial musclature is the only musculature that is "run" by motor rami of dorsal spinal nerves. Absolutely everything else muscular runs from ventral rami.
4. There is no need really, for a sensory or motor homunculus for the spine. It is so primitive that it can be run by a very old and probably very basal part of the system. Or it might even be close to autonomous in its function, certainly self-referent.
5. (So why beat up on it all the time? But that's another thread..)
6. Surely it's the overlying layers, through which the dorsal cutaneous sensory rami have to pierce, that cause problems. That pesky lat. that runs from the brachial plexus. That pesky trap that runs from the accessory. They cover up everything. They are easier to neuromodulate, and likely their motor homunculi are included with that of the neck, and arm, both of which are bigger than the back homuncular representation.
7. When the lats and traps are relaxed, lengthened through eccentric training or through the few minutes that it takes with neuromodulation, the core "back" or "neck" or "spinal column" (now decompressed) regains function (including stability) very easily and effortlessly, with no requirement for forced introduced motion of any sort.
8. Oh yeah, sorry, I don't have any studies backing this up, it's straightforward observation only, based on logic and a smattering of knowlege gleaned from readings of embryology and evolution and anatomy.
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Re: musculoskeletal myths#7 pubic symphesitis - August 31, 2005 9:25:00 AM
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srcase
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Diane,
I think you are definitely on to something here. The lats and traps are so commonly dysfunctional, but I never gave much thought to the dorsal cutaneuous rami which must pierce through them. Thanks for sharing your knowledge.
Sarah
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Re: musculoskeletal myths#7 pubic symphesitis - August 31, 2005 9:35:00 AM
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Barrett
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Diane,
#5 caught my eye: "5. (So why beat up on it all the time? But that's another thread..)
This sounds like a good idea for the Bullypit, or the Open Forum if you prefer-it gets more hits.
I'm hoping you'll start something like "Why do we push?"
Just an idea.
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Re: musculoskeletal myths#7 pubic symphesitis - August 31, 2005 11:57:00 AM
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nari
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Diane
I agree with Barrett - start another thread.
I think the idea is not to 'bash' the spinalators (there, another word) because of what they do, but rather the reason for doing it, and the reason (most importantly) why the patients improve. This is the real crux. Assigning a good outcome to facet joint mobilisation, or McKenzie or whatever other peripheral means which involves joints and muscle, is just not accurate or sufficient anymore.
It doesn't mean spinalators should stop their techniques - it's knowing more about WHY the improvement occurs. And, understanding better the reasons for NOT improving the condition.
Go for it.
Nari
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Re: musculoskeletal myths#7 pubic symphesitis - August 31, 2005 3:56:00 PM
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ginger
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Phew Dianne,re number 8, no need for apologies for having the fluids to flow and the channel to drain them through, very much enjoy your train of thought. Still stuck with the how however . I'm very fond of the notion that primitive reflexes and dispositions are the background to many odd human behaviours. The thread you present here is an exciting one. Evolutionary theory is a hobby of mine after a fashion, certainly useful in my deliberations on the nature and value of "protective responses". Wish I'd more time to go over your material before I dive into the deep end of my working day, later.
Cheers.
Geoff
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Re: musculoskeletal myths#7 pubic symphesitis - September 1, 2005 4:08:00 AM
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Diane
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[QUOTE]Still stuck with the how however[/QUOTE]Ginger, :) , the only difference in the use of the hands is about a 90 degree angle. (OK, just kidding.)
Instead of pinching tissue repeatedly against an underlying bone in the hope of finally getting a bone to move (in the belief that increasing facet joint motion will reduce pain), one can simply place fingers along the SPs or just off to the side of them or a centimeter away from them, stretch skin longitudinally for awhile, stimulate the slow adapting type 2 mechanoreceptors that fire continuously with lateral stretch, don't cause more pain that the brain has to deal with.. I'm not saying that pushing doesn't work, it obviously does or you wouldn't be here saying so, but the stretch way lets the brain do all the work of restoring compliance to whatever part of the "body" you are over that you think you are targeting, while not giving it any reason whatsoever to waste time and effort guarding.
Since you are a farm boy (I'm a farm girl) I'll try an analogy.. say you have a posthole dug. As an experiment, drop your wallet down it. Let's make the hole too small for you to get your manly arm into, and your kids are at school. So you have to use ingenuity; the easiest way to get the wallet out will be to fish it out using two sticks, pinching the wallet in between and lifting it out. You wouldn't want to try just one stick straight in, by poking at it you might just push it in farther.
Hope that makes sense.
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Re: musculoskeletal myths#7 pubic symphesitis - September 1, 2005 8:16:00 AM
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Shill
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Diane.
How might you define a dysfunctional trapezius? I have seen quite a few folks who, after neck dissection for head and neck CA, dont have trapezius any more. Obviously, this is an extreme example of dysfunctional, but having seen some of the extremes, I often find myself questioning the clinical significance of other "trapezius issues".
Just like to get your thoughts on this, and perhaps, as others have said, a separate post would be needed.
Thanks,
Steve
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Re: musculoskeletal myths#7 pubic symphesitis - September 1, 2005 9:51:00 AM
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Diane
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Steve,
[QUOTE]How might you define a dysfunctional trapezius? [/QUOTE]One that is being held too short for the amount of span it is supposed to cover. One that can't relax. One that pulls the shoulders into the trunk. One that pulls the head down making the individual look like a "Kardassian."
It's possible to function with these outer layers removed, as is evident by surgical cases, and the use of trapezius to make stuff, like a new breast for cosmetic purposes etc.. but I can't quite imagine the nervous system liking that too much over the long haul. I suppose that in the case of dissection for reasons of neck cancer, it's a way to buy some time with low survival expectations being a reason to proceed; to heck with quality of life or sense of wellbeing, it's about living a few more months or years, period.
You can visit the thread suggested by Barrett in the bullypit, called "Mobilipulators versus Neuromodulators."
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Re: musculoskeletal myths#7 pubic symphesitis - September 1, 2005 12:49:00 PM
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SJBird55
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Diane, you say that kind of flippantly
[QUOTE]too heck with quality of life or sense of wellbeing, it's about living a few more months or years, period[/QUOTE]Until you or anyone is in the shoes of someone with cancer, I don't think that comment, if I'm reading it in the way you typed it with a bit of tone that quality is more important than time, can be said by anyone unless that anyone is the one making the decision about what is best for him or her. And maybe I take the comment quite sensitively because my father in-law has cancer in which basically the metastasized tumors are just being kept at bay... and concurrently my sister in-law is terminal with a very aggressive uncommon breast cancer that metastasized to her spine, shoulder and brain. "Quality of life" is drastically changed from what I am observing with their experiences. What they focus on is "life" and "living" and they both are making impacts in the lives of many others.... both are very accepting of their current position in life and both have really learned about the importance of life and what really matters in life. My sister in-law is not ready to die and leave behind her 12 year old and her 8 year old... she isn't able to do everything she used to, but she's definitely putting up a fight, focusing on what's important and living whatever time she has for her kids. Her survival expectations were 3-6 months as of May of 2004. You know, I am being overly sensitive about that comment, but those that I love have had a long haul and are fighting the fight AND I can't imagine family gatherings without them (even if it means they need to go lie down and rest/nap for a couple of hours, or they can't go up and down stairs very well, or they can't put on their earrings or necklaces). In my mind, I hope I can be as strong, determined and focused as my sister in-law - for being 42 her quality of life sucks majorly in comparison to those in her age group, but she is living, she does know what's important with life and we love her. Her biggest fear is that her 8 year old son won't remember her if she dies too soon... so, yes, it's all about living and having that time.
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Re: musculoskeletal myths#7 pubic symphesitis - September 1, 2005 1:02:00 PM
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Randy Dixon
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SJ,
It seems to me that she means it the way you are describing above. That their is a hierarchy to life and in some cases having a healthy trapezius ranks pretty low.
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Re: musculoskeletal myths#7 pubic symphesitis - September 1, 2005 1:49:00 PM
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ginger
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SJ, best wishes to you and your family regarding their struggle with cancer.
In answer to your question about setting a pain and dysfunction parameter to view pre and post treatment. I would normaly do overpressures onto the patella in supine, into hip/knee extension , with emphasis on upper and then lower poles. Noting which was the more painful and with what emphssis. There may be palpable tenderness medialy also. Function then , with a progressive squat , noting the level of knee flexion at which pain is felt.In some cases I may observe with pressure of my hand , gripping the VMO with thumb while patient performs a half squat. Noting the recruitment pattern of VMO.
All these pain and dysfunction tests then when repeated after ten to twenty minutes of mobilisation at L3 on the affected side, will be altered to a substantial degree.AND remain that way. There may be a need to tape the patella, generally though I don't unless training schedules are demanding. I always prefer to treat in one way only, rather than muddy the waters with others and then be able to remain confident about results .
All the best
Geoff
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: musculoskeletal myths#7 pubic symphesitis - September 1, 2005 2:44:00 PM
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Diane
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SJ,
So sorry to hear about yourfamily's struggle with cancer. All the best.
I didn't mean what I said to sound flip, meant it more like how Randy read it. If a trap needs to be sacrificed to add more time, fine, not so fine to use a perfectly healthy trap as filler for a new breast for purely cosmetic reasons.
Diane
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