back pain

[physioo]

Had this patient..can u help

33 yr old...runner..c/o LBP muscular L5 level from 3 months...tender on palpation
-On assessment...pain on flexion, mobil spin process..full rom, no pain...no neuro signes...
-Grade 4 lumb extensors...grade 5 abd...otherwise 5 throughout...
-ALso has flat feet..using no orthotics currently

Rx
Advised on flexion to prevent etc..lifting etc
hamstring stretches, knee to chest, rotational stretches in supine lying with knees bent
Strengthening lumbar extensors in prone with 10 sec hold at end of rom.
To continue wearing orthotics for flat feet on running etc.
Heat application 2 times per day..15 mins

What do u think on this treatment, anything else I should test, and anything u would add in Rx.

Thanks guys...much appreciated.

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[nickhedonia]

one of the most common undiagnosed and untreated consequences of the pronated foot posture is the effect it will have on sacro-iliac mobility and thereby the effects on the lumbar spine. It is almost certain that this person will have an immobile pair of SIJ's. Returning mobility to this pair of joints is vital to the long term pain relief of pronators. Mobilisation treatments given to lumbar spinal joints to turn off spinal protective responses is just as important , though the effects will of course be felt almost immediately. Time spent mobilising lumbar joints is the most effective you can offer , providing you are willing to go the distance and achieve full mobility with each joint by being persistant. It is not uncommon for those with Lumbar protective responses to take four or five minutes of continuous mobilisation with each joint to achieve a mobile and painfree result.

[urigellar]

"turn off spinal protective responses".........what exactly are these "protective responses" and how do you propose that mobilisations "turn them off"?!

[nickhedonia]

See post entitled"the physiololgy of spinal pain , a theoretical model" in the general section of this forum, for an explanation of spinal protective reponses.

[urigellar]

an interesting theory, but unfortunately that is all it is and it is a very simple one at that. It is very easy to make pain theories work if you simplify them by ignoring the complexities of pain. In reality pain is so much more complex and has so many other related factors that the theory you propose is naive and shows a fundamental lack of knowledge in this field.

[nickhedonia]

Dear Urigeller, I find a common feature of the students who pass through my rooms and go on to professional life , that such a lot of time has been spent in the acquisition of complex theorems , rationales and techniques, that there is a tendency to think in the complex way it appears is necessary. Often however , this kind of problem solving approach fails to acknowledge what is obvious and simple. As
Occam"s "razor" suggests, the simplest answer is usually the best. What I have set out to do by offering a theorem which seeks to answer the seemingly complex . Is to reduce , as far as is possible , the details concerning each cascade and physiological connection to an understandable relationship. I have used the term " protective response" as the best way I could think of to alert the reader to my proposition . This is , that spinal pain and the attendant referred events, which we seek to treat, have a context that can be understood as"normal". When considered from an evolutionary perspective, those hunters and gatherers that succumbed to a loss of mobility at the effect of spasm and muscular tension leading to pain, were able to successfully reproduce. Those without a means to have potentially catastrophic loss of muscle power and sensation averted , were not successfull.
Like it or not Uri, this model has withstood the attempts by many , including the casual "nay" sayers like yourself , to be sytematically undone. Try some more spoon bending, or have a better go at the theorem from a cool headed perspective, either way , we all win by the debate.
Cheers and good luck with the spoons.

[urigellar]

any theory works if it is over simplified...doesnt mean it is true though........i.e. creationism........ bet you fell for that one too!

i choose simple solutions to complex processes with my patients and it works very well.

[nickhedonia]

your reactionary sarcasm does you no credit Uri, though I may be qualified to give opinion on creationism. At least if the names my patients call me is any guide. Arrrrgh god , is a common one , then there's Aaaarggggh @#%$ as well, or just plain JJEEEEsus, that hurts. I try not to get a big head.

[urigellar]

why do your patients give you such reactions? do you have to hurt your patients in order to turn off the "spinal protective responses"?! Sorry are you a physio or are you involved in some sort of medieval torture? i'd be interested to know who you teach these techniques to aswell?

[nickhedonia]

yes Uri , it is necessary to cause a little pain in the process of reducing the muscular tightness attendant to facet joint immobility. This pain is however a very usefull guide in the course of reducing tone . As the pain is felt at the first attempt to move it presents as an indicator firstly that these muscular( and of course inflammatory ) tone increases are present. As mobilisation is continued, through a range that is acceptable and often quite enjoyable to the patient, the pain reduces as the muscles relax as the resistance to that passive movement decreases. At this point it can be obsereved that freedom of movement has been gained actively as well. Further mobilisation to adjacent joints continues the process untill there is no more to treat , or my time is up ( treatment times are 45 minutes ). Inflammatory change will disappear over the following 24 hours , in direct relation to the amount of joint freedom induced. These are permanent changes. The next steps are to undo whatever attendant dural tightness may have been aquired. In this way the strong likelihood of referred events are also undone. In the course of many thousands of treatments over nearly 20 years I have found that referred events are far more common than many have previously thought. So much so that I was moved to share this information with the likes of colleagues, friends, the general public and yes even the members of my local coven where I regularly bite the heads off live chickens.
Try hard to keep the debate lively Uri , though you would be wise to add more sagacity and less of the sneering know it all fumbling name calling. Listen carefully and even you may learn something of value.I do think however you are more inclined to watch and call from the sidelines than add something of value here.
Oh and by all means have the last word, I can't wait.

[somasimple]

Hi all,

Geoff,

I'm a stubborn guy, too, but I can't understand why you discard systematically the patient intelligence!
As you stated it, as muscles relaxes, pain decreases but it takes time, pain, and thumb arthrosis for the practitioner!

Why do you not try to tell the patient to relax, actively, their muscles. It takes 5 minutes without pain for all! And my retirement will keep my thumbs pain free!

[nickhedonia]

Dear Bernard, in the course of running a private practice it quickly becomes clear that if I don't produce the goods , I won't get any more patients. My business relies on good results , that those who find their way to me after getting off the medical merri-go-round are able to have their musculoskeletal problems eliminated there and then . An average of three to five treatments for resolution and my redundancy with each one is the standard here. Were I to offer exercise based "treatments" no matter how cleverly considered , I would not get those results. I have read your somasimple .com pages with much the same incredulity that you seem to have with my offerings here. I will continue to extoll the virtues of spinal mobilisation treatments, and encourage others of my profession to do likewise, because to ignore the mass of misunderstanding that is apparent from reading these entries , would be to miss the opportunity to make a difference.I believe you feel the same. I will continue to read and enjoy your offerings as hope you can of mine.We all need to encourage each other with as much wisdom and understanding as we are able.
Bon Jour

[somasimple]

Geoff,

I'm in the private practice since 1980, so, I will have the same comment you had!
BTW, you're not replying to my arguments one more time!

I have read your somasimple .com pages with much the same incredulity that you seem to have with my offerings here.

Just register and we will help you to move in the understanding of pain and human beings!

[urigellar]

hi geoff

i sense some anger in your tone? All i ask is a bit more of a clearer explanation of your reasonings. i am in no doubt that your treatments are effective but what are you affecting? Joint stiffness? Muscle tone? or could the pain relief you supply be through more central channels? You will never know which one but to be aware that you could be affecting a lot more than simply 1 facet joint would probably improve your practice no end?
And im sorry if i havent offered anything useful here but these rooms are to stimulate debate not to offer magical answers to all the questions of the physio world! Young physio's need to learn themselves........not just go on the word of a guru like yourself....especially when your reasoning is so poor.

[somasimple]

Hi Geoff,

Here is a cut-away of lumbar area!


This simple view is self explanatory! You haven't any chance to move a facet joint!

[mageshanand]

if you cannot move a facet then what is your explanation for the most popular sacro iliac joint dysfunctions corrected by manipulation.

[urigellar]

no one said you can't move a facet joint its more a case of you can't isolate one facet joint to one particular movement. Also have you ever heard of placebo effect?

[SuperFizz]

This is a very 2 dimensional view. You can see clearly from the image that the facet would easily be move in a lateral way. The L5/S1 disc height is a bit low now for much more extension but I am sure it could flex?

It's great to read your guys comments on manual vs neural vs manipulation as it assists better understanding from all of us. And there are a great many that seem to be reading this forum, not just posting.

Keep up the friendly, yet constructive banter

:hat

[nickhedonia]

I'm overwhelmed by all your attention to my simple messages. Thank you Bernard for the lovely picture, I'm not sure why you've offered this , but I'm sure you have only my best interests at heart. The experiences of these last few weeks have been instructive to me. The Clear message is that there are a lot more ways to skin a cat that I ever thought likely. Some of you like to go about the act by standing at a distance and asking the cat nicely, others sense it purring so are content to leave it alone, more still approach the poor little thing by stealth and surprise it with inspired stroking , others stretch its furry skin and hope for the best. As for me , well I reckon a sharp knife and a few deft strokes would do it. To each his/her own. I think a course on cat skinning is imminent.

[Physiobase]

BRAVO :rollin

[somasimple]

if you cannot move a facet then what is your explanation for the most popular sacro iliac joint dysfunctions corrected by manipulation.

Hmm, your phrase is unclear for me since SIJ dysfunctions is not ever related to a facet joint and vice versa.

I do not believe in a joint cause in these cases since in our body, the only sensitive elements in a joint/muscles/skin/bones are neurons sending stimuli to brain and this one replying by pain (often associated by muscle spasms.) (+ the immune/endocrine systems). I made a change in my knowlege because I'm ever acting on nervous structures before acting on inert/insensitive ones. Sensitive structures (nerves/neurons) may be the key of all of our techniques since they are ever in front line of all of our actions.