|
|
Re: Patellofemoral pain
|
Logged in as: Guest
|
|
Users viewing this topic:
none
|
|
Login  | |
|
Re: Patellofemoral pain - June 4, 2006 5:56:00 AM
|
|
|
PTupdate.com
Posts: 1474
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
Thanks Charles...I think I'll just use a walker, and they can perform the "dip" on that....one of those things where I say "why didn't I think of that"
As far as the spinal issue: Those who know me see that I am constantly trying to learn new, better, and different things. I am quite open to the ideas above, but man, I need some proof.
The stuff Charles and I are talking about has backing, and I can easily run reports on 3 or 4 knee ICD-9 codes to show that we resolve these issues.
Before I embarass myself and my reputation by treating the lumbar spine of a high school athlete with patellar tendinosis, I want some proof. I can't run to my local ortho's and tell them "ginger and nari in Australia said this works great" Nor do I want someone going back to their ortho telling them "he never touched my knee....just my low back...and I am no better"
Plus, I do not want the legal liability of treating someplace other than prescribed. Let's say someone claims a back injury from this, and I get dragged to the witness stand by some slick attorney. The excuse "ginger told me to do it" is a quick way to lose a suit.
So guys, if this stuff works like you said, cough up the evidence. If this effective, there is no reason you cannot recruit 30 patelllar tendinosis patients, perform your lumbar mobilizations, and document the improvements made, and get published. No reason at all.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: Patellofemoral pain - June 4, 2006 6:23:00 AM
|
|
|
certMDT
Posts: 154
Joined: April 5, 2004
From: Durham, NC
Status: offline
|
Nari -
The authors define the patient population:
"To be included, they had to have tendon pain on palpation, symptom reproduction on jumping, squatting, and/or stepping, absence of referred pain outside the tendon, a VISA score less than 80 points, and an abnormal (hypoechoic) ultrasound. Participants were excluded if they...presented with patellofemoral pain..."
Young MA, Cook JL, Purdam CR et al. Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. Br J Sports Med 2005;39:102-105.
The point is that this is focused on patients with pain directly in the patellar tendon, as opposed to the area generally expected with patellofemoral pain. I'm not sure exactly how they define patellofemoral pain, but the lead author is in Victoria, so maybe you could give him a call for the specifics. At any rate, the tracking issues you described would not necessarily be addressed here.
Charlie
_____________________________
Charles Sheets PT OCS Dip MDT
|
|
|
|
|
Re: Patellofemoral pain - June 4, 2006 11:21:00 AM
|
|
|
nari
Posts: 1568
Joined: November 14, 2003
From: Australia
Status: offline
|
Thanks for clarifying, Charlie.
John,
Fair enough. I continually forget the situation in the USA where one must follow a prescription made by someone else or be ****ed.
It is quite different here.
Nari
|
|
|
|
|
Re: Patellofemoral pain - June 4, 2006 2:00:00 PM
|
|
|
ginger
Posts: 658
Joined: February 26, 2005
From: Melbourne Victoria
Status: offline
|
Sarah C, you asked about mobs instead of manips, pulling joints apart is a quick way to improve mobility, some short term effects are usually evident, unfortunately it does not turn off the protective tone of intrinsic musculature sufficient to restore normal movement and inflammation free status long term . Mobs done till tone is reduced do.
If any chiros still connected to the tired old subluxation model were to mob as I do , they would be discharging most of their patients after three treatments as I do , so I doubt there would be any enthusiasm for the continuous method amongst their ranks.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
|
|
|
|
|
Re: Patellofemoral pain - June 4, 2006 2:06:00 PM
|
|
|
ginger
Posts: 658
Joined: February 26, 2005
From: Melbourne Victoria
Status: offline
|
Nari , I can't believe you put the 'f' word in your post. I'm telling your mum.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
|
|
|
|
|
Re: Patellofemoral pain - June 4, 2006 3:13:00 PM
|
|
|
nari
Posts: 1568
Joined: November 14, 2003
From: Australia
Status: offline
|
Ginger
It is NOT that word...good grief!!
It is a word associated with 'dam' and is standard English usage. Why it was banned is anyone's guess.
Nari
|
|
|
|
|
Re: Patellofemoral pain - June 4, 2006 3:57:00 PM
|
|
|
ginger
Posts: 658
Joined: February 26, 2005
From: Melbourne Victoria
Status: offline
|
Nari , your point was that US Pt's are somewhat hamstrung and derailed from pursuing the advantages provided by novel thinking and methods. Hopefully as more states aquire direct access the culture will change. Noone is more qualified to render hands on treatments in the USA than those whose hands are to a large degree, held back by a medico-legal framework that stifles the very free thinking , free living model Americans believe is their birthright.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
|
|
|
|
|
Re: Patellofemoral pain - June 4, 2006 5:23:00 PM
|
|
|
nari
Posts: 1568
Joined: November 14, 2003
From: Australia
Status: offline
|
Yes, I think US PTs in general have an uphill battle. But hopefully that will change in the future with some more chains released from clinical practice decision-making with DA...
Nari
|
|
|
|
|
Re: Patellofemoral pain - June 4, 2006 6:15:00 PM
|
|
|
ginger
Posts: 658
Joined: February 26, 2005
From: Melbourne Victoria
Status: offline
|
Ahh Junction , thank you so much , your interest is great ,just what I need to flesh out some more details. Have to have a few more moments to draw breath and I'll endeavour to reply in as much detail as able.
Just one thing , are you really wearing a white lab coat?
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
|
|
|
|
|
Re: Patellofemoral pain - June 4, 2006 7:01:00 PM
|
|
|
PTdirector
Posts: 11
Joined: May 24, 2006
Status: offline
|
I would also check for femoral anteversion before applying orthotics. Many PFS patients have anteverted femurs and if you apply an orthotic of any kind make sure that if there is a rotational component that it does not end up causing further knee and/or hip problems.
It makes sense that an L3 hypomobility could be an underlying factor in PFS as the quad control comes from this area.
|
|
|
|
|
Re: Patellofemoral pain - June 5, 2006 3:16:00 AM
|
|
|
Tom Reeves DPT ATC
Posts: 445
Joined: March 14, 2006
Status: offline
|
And a hypomobile C4 can cause sleep apnea, and a stuck T9 can cause GERD and pancreatitis, and C7 can cause hypertension, and . . . .
Sounds like somebody has bought into the definition of the elusive chirpractic subluxation.
How can you base you entire clinical practice on the spine? Just because a segment has some relationship with an extremity does not mean that it is the cause of dysfunction there.
PFS is a complex beast with mechanical, neurological (see proprioception), and habitual components. Rarely do my PFS patients have only one of the above.
I think if my patients or my referral sources saw or read of me only mobilizing L3 they would think that I was cracked.
Simple study, have a traditional therapist treat all of Ginger's patients then send a random half of them over for her to mobilize L3 and see who gets better faster.
|
|
|
|
|
Re: Patellofemoral pain - June 5, 2006 5:00:00 AM
|
|
|
PHSPT
Posts: 119
Joined: December 1, 2005
From: Oklahoma
Status: offline
|
I have a question for you Aussies,
Is your type of thinking the standard in Australia? how much EBM (evidence based medicine)do you all practice?
Just curious,
|
|
|
|
|
Re: Patellofemoral pain - June 5, 2006 10:22:00 AM
|
|
|
nari
Posts: 1568
Joined: November 14, 2003
From: Australia
Status: offline
|
PHSPT,
There isn't a standard as such, I think we practice according to what we understand to be the most logical method based on understanding how the body works. The body is complex, but is based on simplicity - the CNS runs the entire show. Unless that is acknowledged, then all the EBM in the kitty may well show that this works for some and that works for others...but looking at the area where pain is experienced and ignoring the rest is a bit of a short-sheet for the patient. The patient functions as a whole, rather than a collection of body bits; unfortunately EBM tends to look only at body bits such as mechanical management of PFS. It seems to forget the CNS.
It is worth remembering that Maitland, McKenzie, Hodges,O'Connell et al are Antipodean; and are known world wide.
So, in answer to your question, if a study or two or a hundred are based only on a mechanical approach, it can miss the boat with respect to long term usefulness. EBM is not a bible to be followed religiously; it is a guideline towards accurate clinical reasoning, and only a guideline.
Tom,
Re subluxations - I have no idea what that remark has to do with anything. Why would anyone mobilise a "subluxed" joint which suggests instability?? A read of some neuroscience literature might help to clear up that notion.
Nari
|
|
|
|
|
Re: Patellofemoral pain - June 5, 2006 12:04:00 PM
|
|
|
Tom Reeves DPT ATC
Posts: 445
Joined: March 14, 2006
Status: offline
|
Nari,
Sorry for the snide uncivil tone of my post. I had just finished with a problematic patient who spends millions at the chiropractors. I was referring to chiropractic subluxations.
A nicer way to say what I said would be that Ginger's descriptions of how to treat everything (or nearly everything) with spinal mobilizations sounds eerily similar to how straight chiropractors treat movement dysfunction or even systemic medical problems mentioned in my post.
I agree that sometimes there is referral pain or radiating pain that can fool clinicians. However, it seems that some people who frequent this discussion board see that perhaps more than it exists.
It may be my bias, but I do not see evidence, logical or published to suggest that patello-femoral syndrome has anything to do with L3, nor do i see anything that would link cervical facet hypomobility to adhesive capsulitis. Though they may occur together, I do not think that by treating one you fix the other. Until someone can logically explain to me how this is supposed to happen, I will treat them the way current science says to do so. If you are successful, please, please develop a paper that eliminates variables and heresay and hypotheticals and anecdotes so that our entire profession can learn and improve best practices. That way obsessive compulsive puritans like me can get better at treating those things that don't get better.
|
|
|
|
|
Re: Patellofemoral pain - June 5, 2006 12:34:00 PM
|
|
|
dfjpt
Posts: 238
Joined: April 9, 2006
Status: offline
|
So... Is it really an either/or issue? Maybe both ways "work": what accounts for the fact that claims made by both Ginger and Tom are likely both right; i.e. that peripheral approaches out in the leg, and "peripheral" (as in, out in the body, in this case on some spinal facet or other), both are adamantly defended as helpful for the problem of a knee that has symptoms, and probably both are equally helpful?
Why?
Could it be that it doesn't really matter where you neuromodulate, the point is to handle some bit of body or skin somewhere, somehow, to give the CNS a new input which it can use as "leverage" to get some bit of itself and its functionally integrated neural "tree" off the square it's on?
|
|
|
|
|
Re: Patellofemoral pain - June 5, 2006 12:41:00 PM
|
|
|
nari
Posts: 1568
Joined: November 14, 2003
From: Australia
Status: offline
|
Tom,
That's OK. Problem patients can make all of us do or say things we don't actually mean to!
I'm puzzled by your comment on referred pain which fools clinicians. Referred pain has been recognised for many years. Are you challenging that a nerve cannot be involved in pain? That pain along the sciatic nerve distribution from the lumbar spine to the foot or knee or calf does not indicate a problem with the CNS? I'm confused.
Cervical spine hypomobility can exist at the same time as a painful shoulder. One may well say there is an association. Whatever the problem is, pain is pain, originating in the brain when a threat is perceived. If you are unsure about that, there is a plethora of books/papers by researchers to support what is now the leading edge of pain management, acute and chronic. Mobilisation of a spinal segment is part of that management - neuromodulation of a cranky CNS. This is thought to be how mobilisation works, which makes more sense than the other hypotheses so far.
Ginger can respond himself in reference to his particular method which is not generally employed to such a degree by all Oz PTs.
Leaders in clinical pain management such as David Butler and Michael Shacklock have written texts to assist PTs worldwide to manage pain from a neurodynamic perspective. It is the only logical explanation to date.
Nari
|
|
|
|
|
Re: Patellofemoral pain - June 5, 2006 12:58:00 PM
|
|
|
PHSPT
Posts: 119
Joined: December 1, 2005
From: Oklahoma
Status: offline
|
"Ginger can respond himself".....
Is Ginger a guy?
Sorry buddy!! i guess i was stuck on Guilligans island....carry on.
|
|
|
|
|
Re: Patellofemoral pain - June 5, 2006 2:32:00 PM
|
|
|
Tom Reeves DPT ATC
Posts: 445
Joined: March 14, 2006
Status: offline
|
Nari,
"I'm puzzled by your comment on referred pain which fools clinicians. Referred pain has been recognised for many years. Are you challenging that a nerve cannot be involved in pain? That pain along the sciatic nerve distribution from the lumbar spine to the foot or knee or calf does not indicate a problem with the CNS? I'm confused."
No, I am certainly not saying that a nerve cannot be involved in pain. We cannot perceive pain without nerves. What I am saying is that it seems that the solution to everything with some therapists is to mobilize the spine.
"Cervical spine hypomobility can exist at the same time as a painful shoulder. One may well say there is an association.
True, but because there is an association, does not mean that one causes or contributes to the other and that is the apparent premise of Ginger's treatment plan. It seems that he/she goes to the spine first for treating everything. I certainly do not go only to the knee to treat PFS but one joint above and below seems appropriate since both the hip and foot directly affect the mechanics of the knee.
In your theory, do the nerve endings ever turn out to be the source of the pain? It seems to me that this may be their function afterall, to help the brain locate the source of the injury. I think that that is the norm and referral pain is less common. It seems that some assume referral pain first.
|
|
|
|
|
Re: Patellofemoral pain - June 5, 2006 5:05:00 PM
|
|
|
nari
Posts: 1568
Joined: November 14, 2003
From: Australia
Status: offline
|
Tom
First of all, it is not 'my' theory; I have learnt it through reading literature by those who are in the business of researching and understanding pain.
Your last paragraph still doesn't make much sense to me...but I am not a mechanically-minded PT. Biomechanic thinking has faded away in relevance once I understood more about pain.
Not sure what you mean by nerve endings. Do you mean that if the sole of the foot hurts and it is resolved by neural mobilisation and/or vertebral wiggling, then you could say that by altering the nociceptive input from a dysfunction in the spine, the entire nerve including the endings is no longer transmitting nociceptive chemicals.
If you refer to cutaneous nerves, they are everywhere and very sensitive to nociception.
Pain cannot originate anywhere except in the brain, but a cause for the perception or experience of pain can arise anywhere. So if there is pain around the knee, or under it, or behind it, there is no reason to think that the cause is definitely the knee or patella. Excluding the spine's involvement is paramount.
And tesing SLR and slump. If they are OK, then there is some likelihood that the cause is local and mechanical.
It is just that you prefer to think in a biomechanical sense - which I know can work quite well, but tends to be slower; and more complex. The premise that pain,posture and muscle weakness are associated at all times is getting less and less credible as time goes by. So is the premise that PFS is purely mechanical; but that has not been studied in depth yet.
Nari
|
|
|
|
|
Re: Patellofemoral pain - June 5, 2006 5:27:00 PM
|
|
|
ginger
Posts: 658
Joined: February 26, 2005
From: Melbourne Victoria
Status: offline
|
Thanks Nari for your explanations and contribution viz EBM etc and the Australian way of doing things . I don't accept any more than you do Nari that there exists here any locked in paradigms or "gold standards " that pushes clinical thinking to behave itself along strict lines. This does appear to be the case in the US.
As much as Aussie physios are taught particular modes operandi , we are also part of a rich scientific and open minded culture that allows for and encourages diversity. I used to think this was also true of the US, however my experiences to date , at least on this forum ,strongly tell another story.
My real wish and fond hope is to participate in a usefull way in a means whereby those methods , observations and techniques that I use successfully every day may be shared. Same me same you.
For those of you not sincere in the business of learning, maybe stick to another forum or just go along with what you know to be ok. For those who really do want to expand their repertoir , alert themselves to alternatives and become more effective , well then lets share.
While I do provide lectures and tutorials on occasion to under and post graduate studeets and teachers, I do not have , at this stage , a solid framework of RCT's, scientific comparison studies or other papers at this time to offer you. Does this mean I won't or can"t share what I see and experience in my clinical life when the questions are asked?. I hope you would agree that there is value in pragmatism , more so in experience, still more in a sincere desire to help those who have not yet had the time or quality of treatment/outcome experience to fully judge the merits of any method.
Why do I approach the spine first?, because in most cases of musculoskeletal pain and dysfunction problem solving , this is the quickest and most powerful way to solve the problem permanently. I rarely suggest exercise , other than an encouragement to stay/become strong and fit. Instead I place my hands where they will do the most good. In most cases what is revealed is that the pain/dysfunction issue resolves quickly and with little likelihood of returning, PROVIDED that the central spinal issue is resolved.
The continuous method of spinal mobilisation has been worked out over many years of carefull attention to what works best. I recommend it to you. All those who find some problems not responding to your " gold standard" attempts at localised treatments or exercise , may want to pay some attention when I describe it.
For those who wish to remain blissfully ignorant and not give it a go , too bad. no skin off my nose at all . The reluctance of some to "give it a go " as we do often say in Australia may well be the reason why you all seem so utterly stuck in the medico-legal framework that tolerates no tactic, no matter how safe , easy to learn or effective that differs from what your doctor/surgeon/insurance Co may require you to do . Wake up America. You are the victims of a system, that crushes the freedoms you so admire.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
|
|
|
|
 New Messages |
 No New Messages |
 Hot Topic w/ New Messages |
 Hot Topic w/o New Messages |
 Locked w/ New Messages |
 Locked w/o New Messages |
|
 Post New Thread
Reply to Message
Post New Poll
Submit Vote
Delete My Own Post
Delete My Own Thread
Rate Posts |
|
0.125
|
Printable Version
