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i have a patient who's been treated for awhile for hip bursitis...he has made significant improvements with ultrasound, acupuncture, ex's and stat bike. He can now walk on even ground with no pain but as soon as he is on rough terrain his pain returns. Any ideas??
Just became a member and have a current patient with trochanteric bursitis with orders to start US. Did you use pulsed or continiuous US? Patient has had progressive pain for 6 months.
Thanks
Diane
I find the diagnosis of "trachanteric bursitis" invariably is a euphemism for " I don't know" and turns out to be just referred pain from protective behaviour at L4. Start there.
I will certainly keep that in mind as there as a low lumbar/sacral component as well. Thanks!
Dear CPD legend
Thanx for the infomation about the possibility of an L4 component to a misdiagnosis of tronchateric bursitis...However, is this to suggest that tronchateric bursitis is not a real condition? from the initial thread, it appears that this diagnosis is pretty accurate suggesting from the improvements made with regards to the specific treatment to the specific problem...just a little confused with your reply...
Yes , it is clear that treatment to the complained of structure in situations when the pain is neuralgic , will provide brief periods of relief. exercise in general will induce positive changes to the lumbar protective behaviours that had been the direct cause of that neuralgia. In 25 years of consideration of MSK complaints such as the one mentioned, "bursitis" of any kind is rarely, indeed , very rarely the real diagnosis. In most cases the "diagnosis" had been made without any or adequate consideration of central ( spinal ) mechanisms.
Thank you Ginger...Most definitely spinal mechanisms have got to be assessed to rule out this as a cause. My experience so far tells me that bursitis is not a standalone pathology. Infact, if this is occuring then something predisposes to it. it may be arthritis, muscle imbalance or primary tendon issues/over use. It just gets complicated when there is a combined spinal problem and you have a referred pattern but bursitis can exist and when we examine a patient localised movement of the joint in question, behaviors at night, inability to rest on the affected part would suggest so. Also when we palpate we might have an incline to this. Often enough, symptomatic management, attempting to corect predisposing factors are the means of managing.recently seeing a man who is suffering fromrotator cuff lesion now with an inflammed subacromial bursa, he however has some symptoms suggesting C6 involvement but his shoulder issues are definite.
If the treating therapist is unsure, an
Hi Dr Damien,
Without speaking for Ginger, I think perhaps Ginger means that whilst there may be a pathology you can see, the primary problem is from "lumbar protective responses" causing alteration of function and subsequent hip issues - would i be accurate with that Ginger?
I would then hazard a guess that Ginger would recommend treatment using continuous mobilisations to the L4 region...possibly to restore "normal" lumbar motion and function and thus decrease the physical loading on the "bursitis" which is the presenting symptom (and not a diagnosis of why they have pain but simply naming the structure that is painful)...
If the above is true, then i wholeheartedly agree that L4 could be a primary cause...but i would also check to make sure that L4 wasn't dysfunctional because of some other reason.
Basically one term to use is "Failed Load Transfer" (FLT). Engineers use it to describe what happens in their materials and joins etc. We can use it to describe problems in the body. To my mind, the first body part/joint that demonstrates FLT first is the primary problem. This can be difficult to tell as timing can be close to each other...However, just as firefighters can trace back a fire to its original ignition and investigators can tall what happened to the plane that crashed, so we too as physios can tell when something fails first and causes a cascade of dysfunction - this pushes all the affected parts towards their physiological limits and the weakest link is the one that breaks and gives you "symptoms".
Also, Trochanteric Bursitis is a bit passe these days (apparently)...it is usually referred to as "Gluteus medius tendinopathy"...apparently no inflammatory markers in the painful "bursa" but tendinopathy present...
Cheers!
Alophysio and Damien ( let me know if you have a Phd and I'd be only too glad to add the honorific on later posts)
"the primary problem is from "lumbar protective responses" causing alteration of function and subsequent hip issues - would i be accurate with that Ginger?"
Almost.
The alteration of function is of the spine ( for detail of this I will direct the reader here The physiology of spinal pain. A theoretical model ), where an innate protective behaviour reduces movement by inducing higher paravertebral tone. This often leads to spondylitic irritations to nerve roots, which give rise to altered sensations, pain and altered patterns of recruitment of muscle. Referred events also include the effects brought about by induced changes to parasympathetic neurology, including puffiness, local colour changes, altered circulation, inflammation etc.
The "Hip" issues when these arise are brought about by pain patterns programmed in the brain , responding to nerve root nociceptive input, mapped out according to those nerves ( the brain does not recognise structures, only nerves).
First duty of any investigator is to pay attention to the most likely first, that being, that where no trauma had been a feature of the sequence of events leading to pain, that the spine plays a major role in the pain and other symptoms. I find this is invariably true when dealing with "bursitis', also with "tendonitis". For the most part these diagnoses require, at the very least, a thorough consideration of the spine.
By thorough i do not mean slump or neural tension testing, palpation of the complained of structure ( tells you nothing of value) or observations of periodicity of pain. The only reliable way to be able to confidently rule out spine as cause, is to follow the Cm protocol.
To Ginger (my words below are with love)
you are hilarious..., adding DR or not makes no difference to me(laughing)...this is not a place for flexing honors, its a site to share knowledge ...Its my username, this is no ward round or academic lecture theatre, I dont change peoples usernames simply because I want to or its not my cup of tea, ... if you have a PHD, kudos to you, if your username spelt Dr Ginger, thats what Ill call you, it would be silly of anyone to assume usernames are really peoples names or titles, so try and stay humble....lol
I can call myself professor Mushroom, Mr crutches or sargent ultrasound, it really shouldnt matter to you...
Coming back to the discussion, Alophysio's comment is much appreciated because what we habitually call bursitis can infact be gluteus medius tendinopathy or tears(which often is the case).I personally do not know any physios that assess the spine in a wish washy manner that you described (at least not me). I have asked if this pathology is a myth in ur own experience and that all cases have infact been spinal mechanisms? The theoretical lecture is much appreciated, please answer the question...a yes or no will do me just fine...
question 2, what if you have ruled out lumbar spine as a cause but the hip pain persists? would you consider that the pathology exists then?
What I know is that if anyone presents with what appears to be "bursitis" this is not likely to be the main problem...instinctively I am looking for other reasons for this presentation...the lumbar spine is never far from my assessment, infact it is usually the place to start for any seemingly mechanical pain below the thorax...
You know what dont call me Dr damien, come to think of it I think I prefer DAME EDNA? lol
Dear Dame Edna, I wanted to be called The Grand Poobah and even investigated getting a sceptre and ocelot cape to go with the title ( for state occasions only of course ) but came to the conclusion , after much soul searching, that keeping to a seemingly irreducible sobriquet harking to my Scot roots was the best way to remain memorable , while not offering offence to anyone with the surname Poobah. I think the name Damien is distinguished enough for present company, but if you prefer, Dame Edna, so be it.
Question 2. Probably, but without direct evidence of pathology ( scan ), implicating the hip joint I would be left wondering where my consideration of other cause had left something out. I have not had occasion to confirm any diagnosis of "trochanteric bursitis" in 25 years of careful attention.
I have had occasion to consider there may be "busitis" ( too long spent in public transport ), "biscitis"( over eating choc cookies) and "basitis" ( marginal tone deafness in the lower register brought on by use of headphones). The elusive "bursitis" however I suspect may be on the same level phenomenologically, as the Thylacine.
Hope this helps
thank you spice girl, i kind of like the ring of the grand pooba to you, its befitting, ...lol
I also think the diagnosis of throcanteric "bursitis" should better be left out from the "physio-dictionary".
The main reason being that you would think you treated an inflamed bursa, something I believe would be difficult to prove and treat clinically. I find no trouble in adopting to the term "greater trochanteric pain syndrome" as the greater trochanter serves as attachment of five muscles (gluteus medius/minimus, piriformis, obturator externus/internus) and is closely surrounded by 3 bursas, the subgluteus maximus bursa, the subgluteus medius bursa and the gluteus minimus bursa. Considering that the subgluteus maximus bursa is subdivided into at least 4 smaller bursas and together with the subdivisions of the subgluteal and gluteus minimus bursa, you'd have a minimum of 9 or 10 bursas all together. On top of that, taking into account the individual anatomical differences AND that there is no bursa that is really anatomically named the trochanteric bursa, well............ Making a differential diagnosis between the 5 muscles and the 10 bursas would also make up a good challenge, considering that passive/active movements could both stretch myofascial structures and/or compress the bursas.
I think it's a bit dangerous to "conclude" that the diagnosis was accurate, based on improvement to the specific treatment given, as someone suggested earlier (but he was probably just playing devils advocate ;)). It could be several reasons for that improvement (placebo, regression to the mean, natural history of condition, etc, etc) and I personally try to challenge myself always suggesting the opposite, to never believe that the patient is improving due to anything I do. I find this keeps me on my toes, as I then always have to clinically prove to myself (and the patient), that what I did/said, really had a positive influence on the impairment.
I also honestly believe, that the management of this/these condition(s) would be exactly the same, pain being caused either from structural myofascial/bursa or due to central modulatory issues, appreciating the fact that there is never either the one or the other alone. Obviously, the stage of the condition (acute, subacute, chronic) would dictate the progression (how much time spent on each intervention, manual work vs. exercise) throughout management, thinking of the possibility of gluteal tears as mentioned in previous posts. I'd focus on a functional approach, starting with nailing down exactly where in the step the patient gets the pain. I'd then analyze what component in that position could be contributing to the gaitdysfunction (pain, stiffness, weakness) and then manage the main component (painmodulation, stretching, strengthening) alongside a gradual exposure approach in terms of functional motor control exercises (taking feedforward-mechanisms, neuroplasticity, movementspecificity into account).
And I would also ALWAYS check the lumbar spine (and hip joint) thoroughly, also as mentioned in previous posts, as possibly a primary source of pain (somatic referral from segmental structures or neurogenic interface) or as a contributing/maintaining/predisposing factor feeding into the hip pain. I guess this is where the real discussion started ;). I assume it is clinical experience/observation talking when the L4 is mentioned so specifically? Personally I haven't found one of the lower lumbar segmental levels to be dominant in hip pains, as the hip could in reality be the endpoint of both sensation/motor innervation from almost any structure of the lumbar spine...?
Referring back to katiemac70 initial post, I'd think that walking on even ground and rough terrain would be two quite different motor tasks (also possibly requiring different brain "maps" in the motor cortex) and would use the same approach as mentioned above, but considering that this is a whole new setting (rough terrain). I'm tempted to think that if the patient is able to walk perfectly on even ground, that there is no longer any issues about local hip pathology (or never were), and focus even more on the functional task-specific movement components required for walking on rough terrain. Identifying where in the movement (dominantly while stepping up or stepping down from a height vs. timefactor) would probably be a good place to start.
Wow SIGMIK
impressive...I can see you are or probably approach musculoskeletal issues from a neuro perspective, which is often the better ways to go, you are right, exploring that activity that aggravates the problem, might be a better approach, it may seem time consuming but in the event of problems being vague, functional approaches will bring things into better light. This still comes to the issues that have to do with muscle imbalances(as vague as that term sounds).
A thourough examination of the lumbar spine, hip and
cheers for that good post...
Thanks for the feedback, Damien. Appreciated!
You are spot on, after chasing different approaches for a long time, I now often find it difficult NOT to take into consideration the findings from neuroscience perspectives. It also fits perfectly with evidence from ie. Tuttle et al, that within-treatment changes are predictive of end-treatment changes, but ONLY in those parameters measured. The research group thus highlight the importance of functional reassessment markers, but from a totally different approach than the neuroscientists. I find this match very appealing and clinically helpful! Totally agree that it seem (and often is) time consuming as I find it needs a different level of patient compliance, but it does bring things better into light.
LOL, in regards to "muscle imbalances", I'll probably never be able to wrap my head around that one. I don't often find muscle imbalances as in tonic/phasic terms to be very helpful, as it's often based on a set of assumptions and not on "clinical evidence"? Not that I dismiss the relevance, but I've become more confident with the terms of inadequate motor patterning/control as a result of altered neuro-output being a consequence of dysfunctions and pain (didn't really express that very well - bear with me). Anyway. Seems like our profession is expanding as more clinically relevant evidence is put forth, and I think physio's (and other practitioners that are willing to look into it) have a very interesting future ahead.
Kind regards,
Sigurd Mikkelsen
Hi SigMik,
Thanks for your posts above. I agree with what you write.
However from a practical point of view, i am not sure that most physios would be able to challenge themselves into thinking they weren't making much difference and protect the patient from the doubt. It is the very fact that you challenge yourself and seek other approaches which allows to you be an excellent clinician.
Whoever said that the placebo effect is not a valid effect to utilise?
Am i a fraud if i am confidently able to outline the "normal" recovery process and guide them along it?
I think it would be unethical of me to get the patient to rely on me to get better - i am not advocating that...
...however, my patients trust me, they believe i am caring and confident in knowing what to do for them (including NOT treating them if they don't need it or referring onto someone else who is better suited).
Your words and explanation of how you approach a problem functionally and taking into account all the systems possibly involved is to be commended. I wish there were more physios out there who were more like you...
...unfortunately, the gap between knowledge and clinical practice and the ability to implement effectively what we believe is the main problem that i see.
I know lots of physios who are pretty useless when it comes to knowledge - it is all undergrad stuff with minimal post-grad courses taken or active revision or reflection done...but they are awesome physios because they inspire confidence and trust in their patients, as well as not making them worse. I learned this lesson early on and i have never forgotten - it is not about how good you are at assessment and diagnosis, it is how good you are at being confident, competent, and communicative with your patients.
As for muscle imbalances, it is merely a phrase you describe (probably inadequately) the idea that a particular area is overactive or underactive or excessive shortened or lengthened - which neatly summarises the things we assess (because we know the different things we are assessing) but perhaps gets used too loosely by people who mean it to be "something wrong" with your muscles.
As for DrDamien's comment - his description of your approach from a neurological perspective would be a little inaccurate would it not? It would seem to me that you have emphasised the neurological aspects in this discussion (and probably others because it is quite often lacking) butwouldn't your approach be a truly neuromusculoskeletal approach - what we all should be doing?
Anyway, it is good to see you on the forum and your particular point of view is very welcome here and no doubt sorely needed ")
CHeers
Dear Alophysio,
I am truly grateful and, flattered, of your constructive feedback. These are words and genuine, reflective thoughts clinicians don't get to hear too often from fellow colleagues, especially not when working in a busy private out-patient practice like I do. So again, thank you for that.
I see your point, and from a sound pedagogical perspective, I do agree. But I've also challenged myself and sought other approaches, and thought I was an excellent clinician. But what did I challenge? What did I do with those other approaches more than expanding my technical repertoire? My comment about how I never believe that the patient is improving because of what I do, is just a mental and brutal reminder that is back of my head - to never assume anything and try to prove to myself and equally as important, to the patient that what we just did, made both clinical and functional sense. There is so many good advices to give and I find this harsh reminder to make me think twice about what advice I give. Also clinically with techniques, it has helped me to identify which technique has the better effect over the other at an earlier stage. Call it Murphy's Law... Or even better - Ziggy's Law of Manual Treatment... ;)Quote:
However from a practical point of view, i am not sure that most physios would be able to challenge themselves into thinking they weren't making much difference and protect the patient from the doubt. It is the very fact that you challenge yourself and seek other approaches which allows to you be an excellent clinician.
WHO said the placebo effects is not a valid effect to ulilise??? Certainly not me I hope!!! ;) It is a matter of identifying how much effect do my particular intervention, have BEOYND the placebo effect! This also accounts for the other possible effects of improvement as I mentioned. Placebo is the therapists best friend, just as the dog is for the Man! I have some colleagues, who get a bit puffed up, when I talk about the placebo effect, and I do not understand why.................... It is to my greatest delight that the latest decade have started to shed light on the actual biochemical process of placebo, by means of fQuote:
Whoever said that the placebo effect is not a valid effect to utilise?
My point being, from the context in my previous comment where I mentioned placebo, is that in this MIST of all potential natural, unnatural, magical wish-wash and other logical causes for a patient to improve within a treatment, it is important not to assume anything, but to use sound clinical reasoning as a means to navigate safely. I hope you see where I'm coming from.
Not at al. In fact, I think this is the area where I have improved most, to suggest a possible prognosis, based on age, general health, psychosocial factors, pathology, stage, stability, natural history of conditions, treatment-response, etc, etc, etc and so on. It is an important skill for physiotherapists to develop, as this will make us stronger as a profession, and will add to the identity our profession is struggling with. I hope I'll continue this "improvement" as it also helps me sleep better and let go of those I am not able to help.Quote:
Am i a fraud if i am confidently able to outline the "normal" recovery process and guide them along it?
Well, I'm still working on that gap. I used to have great knowledge, and I've always been confident as a practitioner. It was a difficult process for me to realize and admit that clinical reasoning is the bridge in between.Quote:
The gap between knowledge and clinical practice and the ability to implement effectively what we believe is the main problem that i see.
I think I see your point here, and am not even really sure if I know what I tried to say... ;) But what I think I tried to say, is that I've seen people looking like the Hunchback of Notre Dame and repeatedly asked them "are you sure you've never had any problems with your shoulders?" in which they replied a simple "no". Repeatedly. I'm very well aware of Shirley A. Sahrmann's work about diagnosis and treatment of movement impairment syndromes. I think my main problem here, is that I'm not able to link observations of tonic/phasic postures, overactive/underactive and so on - to clinical evidence. I mean, I do observe these situations, but have problems in concluding on a causality. It's a lovely concept, it's all very logical, for me as a therapist and often to the patients, but I just find it so much easier to treat and re-assess. Treat and re-assess. Treat and re-assess. So what are we doing to a tight muscle? Stretch. Or MET/hold-relax. Is that tight muscle really a comparable sign, worth of treatment?Quote:
As for muscle imbalances, it is merely a phrase you describe (probably inadequately) the idea that a particular area is overactive or underactive or excessive shortened or lengthened - which neatly summarises the things we assess (because we know the different things we are assessing) but perhaps gets used too loosely by people who mean it to be "something wrong" with your muscles.
Then I came over what I consider as sound work by Joseph Threlkeld, Patrick de Deyne, Mitchell, Feland, Ballantyn, Fryer, I could go on. METs and hold/relax only seem to alter the perception of stiffness, therefore after a few reps, people are able to tolerate more stiffness/stretch. That's good. But no real muscle change really. And what about the biomechanical mechanisms (visco-elastic behaviour issues), neurological mechanisms (no reciprocal or autogenic inhibition present) and even what happens on cellular and molecular levels? If stretched, the muscle will respond (in addition to release of insulin-like growth factors) with myofibrillogenesis = addition of sarcomeres. Is this likely to happen within one treatment session? Will I be able to prove this change from observing a tight muscle, stretch one muscle to improve the muscle imbalance? What really happened when I stretched that muscle? But true as you say, all this "stuff", probably gets used too loosely by therapists who mean this to be "something wrong" with your muscles...
I don't know. I'm not sure. We'll all have our areas of interest, and there are definitely many roads to Rome. I only take on board the findings from recent neuroscience, about pain perception (in reality, perception of anything) and cognitive aspects. The importance of mindfulness, being present, focused on movement - rather than pain. Both pain and movement is neuro, isn't it? That's what we all should be concerned about, or not? But it's is really a true pain in the #*$& sometimes, as Damien correctly points out, it's time consuming and I've become more to terms that it needs a different level of patient compliance. Or communication from my part. ;) I'm seldom able to get people with "fix-my-car" attitude a lot better. But I've just started on this "stuff". I'm curious of where I'll be in say 5-10 years as a therapist.Quote:
As for DrDamien's comment - his description of your approach from a neurological perspective would be a little inaccurate would it not? It would seem to me that you have emphasised the neurological aspects in this discussion (and probably others because it is quite often lacking) but wouldn't your approach be a truly neuromusculoskeletal approach - what we all should be doing?
Thank you again. Your comments made my day. :)Quote:
Your words and explanation of how you approach a problem functionally and taking into account all the systems possibly involved is to be commended. I wish there were more physios out there who were more like you... Anyway, it is good to see you on the forum and your particular point of view is very welcome here and no doubt sorely needed ")
Kind regards,
Sigurd Mikkelsen
HI SigMik,
You are welcome - Thanks for your consideration of my comments.
I will only add to clarify my point about being truly neuromusculoskeletal...Every system in the body is related in some way - your shoulder is not just a shoulder joint, muscles, nerves, vessels etc but a part of a system where each element that comes into the area - whether just passing through or through direct attachment - can be affected by other areas.
Thus,, for each area, you would have to consider the neurological, articular, myofascial, visceral and pyschological systems involved for that area (the shoulder) and every other "joint" that those elements (nerves, mm, tendons, fascia, etc) cross...
Thanks again for your contribution to the forum...and for Drdamien's as well and numerous other valuable contributors.
Hi
I have a patient that has been diagnosed with hip bursitis. When one finds that L4 is involved-what specific techniques would you use to correct it?
Hi, Fouche.
My answer will be based on the assumption that you have applied "direct" pressure to the L4 segment and by that partially or fully reproduced the patients hip pain. If this is false, please provide information on what different method you used to identify the L4 segment as a component of the hip pain.
My initial choice of technique would be a postero-anterior mobilization technique to the area which reproduced the patients pain the most. I would also try to locate which direction this pressure reproduced the sym's. For example, you often will find different symptom response if you do a cephalad or a caudad directed mobilization. And equally so with a medially or laterally directed technique. Play around, pick the level/direction that reproduces the most. Apply the technique (goes for all techniques in general) accordingly to the patients severity and irritability (and nature) and always make sure the patient is treated within his/hers acceptable limits.
The next thing is patient position. This has been an eye-opener for my part as I've many times gotten really good results on reassessment when I "nailed" all components - for me the main component has been patient position while technique is applied. In which activity/test position does the patient reproduce the sym's? Is it while the hip is extended/flexed, up/down steps, leaning forward/backward/sideways/rotation/combined, etc. Now, try to replicate that position. You've now got two choices - either replicate something like that position on the plinth - e.g. flex the plinth, put patient prone to replicate standing forward flexion, or extend, rotate, etc... Then apply the mobilization in that position. Your other choice is to simply add the mobilization technique in the specific position the patient gets his/hers pain. E.g. in standing with affected leg just about to take a step up/down and so on. Hope I was able to describe that adequately... If the patient is in too much pain (likely not with a hip "bursitis") lie the patient in normal front position, find the direction as I talked about and go on.
Another thing to consider, or I should probably say, one thing that I considered before, was how much pressure should I give, at what rate? There's good indication from very recent research that the effect of these kind of spinal mobilizations are not significantly different if you give 50, 150 or 200 Newtons of pressure or a rate of 0.5 Hz, 1 Hz or 2 Hz (1 Hz = 1 push per sek) or even static pressure of 200 Newtons. These results were based on 1 minutes applied 3 times with 30 sek apart. 200 Newtons is about 19 kg I think, and is not much, most people would apply more, everything up to 45 kg. The point being, it doesn't really matter how you apply it... Just do something. ;) More importantly, observe how the patient responds when you apply them and adjust thereafter.
Always remember to reassess!!! That's just one technique, would be nice if some other people also gave some input on other neat stuff to do.
Good luck! :)
Hi fouche,
Thanks SigMik for your comments...very useful and insightful.
For me, it is all about the questions you ask - of the patient, the patient's body (thru your examination) and challenging beliefs and assumptions...
First question - how does the pain affect their functional activities - walking, stairs, slopes, sit-to stand, stand-to-sit, lying down, getting out of bed, sitting etc?
Next question - What is the significance of their pain? DO they have an altered perception of how large the area is or does it seem to be of a different magnitude of pain to the problem? If so, they might need pyschology as well...
Next question - what is their story and the meaning of that story in their lives - e.g. Have to get rid of hip pain to play in grand final this weekend...because if you fix their pain but can't them to play in the final, they won't think you are very good but if you can get them back in the final even with pain, they will love you...your approach will depend on their goals.
For example, a diagnosis of troch bursitis has been given to you - great! But how?
Because they had lateral hip pain and the doctor took a stab at the diagnosis?
Or they found swelling and degeneration in the lateral hip area somewhere on U/S or
Or because the pt looked it up on Google? Was it a specialist doctor who is on the top of their game and NOT "cut-happy"or a general practitioner who prefers to see nursing home patients?
All of these things make a difference.
The diagnosis of Troch bursitis is merely a description of where the possible source of pain is for the pt. Perhaps it describes a pathology that has been observed...BUT it doesn't tell you WHY they have an inflamed bursa, degenerated tendon or even why they have pain.
Ok - how did you find that the L4 has a component to the pain?
Was it by examination?
What component of the L3/4 or L4/5 complex was involved?
Was it the nerve, the muscles or the joints?
Is the L4 the primary problem that is leading to the hip pain or is it simply sore because the hip is causing altered biomechanics which has stress the L3/4 or L4/5 complex?
All of those questions need to be answered before you can formulate a treatment approach.
Asssumption: L4 is a secondary problem
* Find the primary problem - check the hip, the
* Treat the L4/5 or L3/4 segment as you see fit to relieve any pain but know that it is only symptomatic relief. You will be better off finding the primary problem and then clean up the secondaries later...they are often less sore and the pain doesn't come back as bad
* If you can't tell what is primary, then treat what you think is the primary - if you are right, the pain won't come back after a matter of hours, minutes or even a day or two. People who keep plugging away at problems without the patient getting better are not treating the right problem!!
Assumption: L4 (L3/4 or L4/5) is primary problem
* It will FLT first - hard to describe but it will often rotate or shift near the initiation of movement in that segment and all other joints will FLT after that
* If it is a joint problem, treat the joint - facet or disc using mobilisations, manipulations, etc etc - that is undergrad stuff. The stuff that SigMik said is great - that is beyond undergrad stuff because it is hard to teach someone how to repos if you don't have a patient to teach them on
* If it is a muscle problem - overactive, underactive, too short or too long - then treat it with what you know - soft tissue massage, acupuncture/dry needling, Muscle Energy Technique, stretching, exercising etc etc etc - there are lots out there for it.
* If it is a neural system problem - pinched/irritate nerve, neurodynamic problem, motor control problem, etc etc - then do that stuff
Once you have released what needs to be released in the (usually) joint, myofascial and neural system, then get proper alignment and posture going.
Then reassess their pain during functional tasks
If they need a cue to keep it all together, then give them one - keep you back flat, stick you bum out a bit, tuck you bum in a bit, think taller etc etc etc
Once they have all that together, then teach them how to do their functional tasks again with new patterns of movement and the FLT should disappear and thus the FLT won't cause excessive loading on the hip joint leading to "troch bursitis".
Hope that makes sense to you. It gets clearer for me each time i tell people what i do :D Mind you, i have spend 10's of thousands of dollars on courses etc over the years to learn this stuff...have fun with it :)
Cheers
Excellent post, Alophysio, great that you took it into the broader picture! Starting to get an impression of how you work, and it's stimulating to see different approaches to a problem. I've looked a bit, unsuccessfully, on the forum and googled for information about the FLT you talk about. Would you mind directing me towards any sources or explain a bit more about this observational tool? From what I can read, any joint moving first - fails the load transfer test? And where do you go from here? How do you perform these tests? Again, I enjoyed that post, thanks!
Ziggy
Dear Alophysio
This approach of managing a patient is not new. I believe its something that
Having read your comments, I believe its purely common sense for anyone who is addressing any mechanical issue to consider the body as a whole because every part is linked. It takes years of training and practice to acquire the skill that you clearly have...
However, this is nothing new to be honest, on a very basic level...its the same concept that is put into practice when a shoe raise is prescribed for a limb length discrepancy... its all about understanding the body biomechanics and seeing the whole body as one not individual parts...
Bobath therapists start by understanding what "normal movement " is, deviations from the norm is what we try to correct. I think we are all saying the same thing but speaking different languages...
Why I was impressed with SigMik's comment was because I thought only bobath therapists assess that way, but clearly it is a holistic problem solving approach.
It is the same reason why we treat someone with an impingement syndrome, we no longer treat symptomatically, we aim to address the faulty biomechanics that are resulting in the impingement...
Some author will wake up tomorrow and give this old concept another name...he could decide to call it...reverse pathomechanics and start a whole doctrine on something that isnt new but make it appear new...
why do scoliotic clients sometimes have backpain, or why would having a forward neck give you back pain, or why would having pronated feet cause back pain, or varus knee give you neck pain, or an LLD cause back and hip pain?
In My own experience, I have found that this approach cannot work for every single patient because the question still remains who are we to define normal movement or appropriate biomechanics? what is normal for you may be abnormal for me?...where there has been structural changes, this aapproach will not work...this is where you begin to start thinking of adaptations.
It is theoretical to explain but the reality is that people come in all shapes and sizes. Perhaps in an acute case in a young client you might be able to apply his approach, however the body has a way of adjusting to the forces it experiences (sometimes for good sometimes for bad)...attempting to align one part to address one issue can easily also cause a malalignment some where else making things complicated... this is why sometimes symptomatic management is fine for as long as a patient gets relief and is left with good advise and being well infomed of what the problem is and how to self manage...
I think I say this because right now I am basically seeing elderly clients wherein they do not follow the norm of what our trainings or courses have to offer...
A typical example...
saw a man with chronic back pain (greater than 15 years) with a clear small kyphose lumbar spine, extreme caps limitation in the spine, pelvic obliquity, with a forward neck...this man was roughly 6ft three had a protruding stomach, he was 83 years old...osteoporotic generally...history of a heart problem etc... can hardly stand up straight,
howver way I understand the pathomechanics going on...it is unlikely that any of my myofascial release, realignment and postural correction would make a difference to this mans symptoms...Things have become structural...im likely to cause more damage by applying any phsical intervention...
Another example, 19 year old cerebral palsy with tight adductors, plantarflexors, lordotic spine and retracted neck...where do you want to begin to address any pathomechanics, some surgeon was suggesting surgery to elongate the tight muscles...only problem was this was likely going to cause major balance issues as this boy had adapted to the postural control he had learnt since a baby...
I agree with you that a better description would be to call it an awareness of the neuromusculoskeletal system as a whole...there is an author sharmann I think his/her name is and they popularized some aspects of understanding movement disorders like the one you describe but the reality is it is not a new concept...
Based on what you've said, I agree with you that it should be an eye opener for all physiotherapists in general to understand the science of movement better...I have always felt it is easier for a neuro physio to have this skill than most other physios because they tend to see patients with a global movement disorder as opposed to MSk physios who are more likely to see patients with apparent localized problems...
cheers
Thanks SigMik and DrDamien,
about what i wrote DrDamien, i don't believe i have ever said that this is new or not done before. In fact i reference the fact that i have spent lots of money learning these things...which implies it is not new...
As for your 83y.o. man, you simply agreed with me :) It has become structural - that is joint pathlogies have caused structural changes which physically limit this man's ROM...however what is functional for this man? Does his joints work properly in the positions that he is in. It may well be true that we cannot help him and i agree that "myofascial release, realignment and postural correction" would not make any difference but that is the point of the assessment procedure i outlined above.
I guess my point is that there are physios who would try to do those things which wouldn't likely help...
...but i have a better example for you...
90+y.o. woman who came in unable to look parallel to the ground. Severe kypho
I assessed her, found FLT in her ribs, released the myofascial structures causing a problem and in 2 sessions she was painfree and back to normal ADLs. She didn't look 1 degree straighter but she was back to her "normal"...
The author you refer to is Shirley Sahrmann - she has an interesting point of view - one that i think is coloured by the fact that US physios often only get a handful of funded sessions from private insurance companies so she does very well with chornic pain in limited time but there could be so much more elegant things done with her work...
Lastly, again, the concepts i talk about are not new, just not common. That is why i talk about them. Hopefully people get interested and try to broaden their experience...
SigMik, The Pelvic Girdle 4th edition by Diane Lee and LJ Lee (no relation to each other) will be out very soon. Stuff will be in that but it is the overall concepts proposed by Panjabi, Vleeming, Lee etc thru various models which ask therapists to think of different systems throughout the body.
To be good at detecting FLT, you have to know what "normal" is so Shirley Sahrmann's book, kendalls Muscles Testing and function book etc outline normal muscle and joint motion so you will then see poor movement patterns and FLT.
Examples of FLT you are already aware of (no doubt):
- loss of ER control of hip during squats, STS, lunges, step up/down etc.
- overpronation at the feet during WB
- anterior shoulder translation during GH movement
- Scapula winging during loaded shoulder girdle movement
Examples of FLT you may not be aware of... but play with them and see!
- uncontrolled lateral glide of C/S during arm movement - cervical column should not move if your head is stationary.
- Hip anterior translation during increased WB or in NWB
-
- excessive L/S rot during sagittal plane motion
Have fun. Happy to help out more but have to run.
Drdamien, i hope it clears a few things up. I am sorry if you got the wrong idea. :D Cheers!
Hi guys,
Really interesting responses which have definitely made me think about and reflect on my assessment, clinical reasoning and practice.
Can I just ask what is the Cm protocol to rule out a spinal cause which was mentioned earlier and in the thread and where could I find some info/references about it (a googe search wasn't too successful)?
And alophysio, I take it spotting the primary problem comes with time, practice and experience? Have you got any tips for best way to observe the different areas that could fail all in one go? I guess what with my limited experience it is obviously easier to identify the more noticable of the FLT areas but that could not be the first to fail.
Thanks for sharing your expertise and experiences,
Ed
Hi, Ed.
I'm a bit short of time these days, so my comments are a bit stumped, BUT:
- I've been going through these issues several times, observational findings, i.e. is it really a dysfunctional movement or not? Is it related? In which way? Is it dysfunctional due to compensation because there is pain inhibiting movement another place? Neuroscience research points out (what we all knew), that let's say you hurt your finger, the shoulder muscles will actually get inhibited. So if the shoulder is observed to move not optimally, will a correction of the shoulder make the hurt in your finger go away?
- Alophysio, you say that to be good in detecting FLT, one need to know what "normal" is... Normal? I know you can give me a better explanation than that! ;)
- I'm thinking that findings like FLT positives will be heavily influenced by observer bias, when I think I have observed something of importance, I'm probably going to project this belief to the patient as well and even give a more convincing treatment
- I'm doing my dissertation on reliability of PAIVMs, but it didn't take me long to see that studies on observations or palpation of movement ARE NOT RELIABLE and will never be.
These comments does not serve justice to Alophysio's and Damien's last well-tought of posts, but I just had to let it out. I'll try to contribute more next time I post when I got a bit more time...
Hi Ed C and SigMik...
1. CM protocol - i think Ginger likes to refer to a post he put on RehabEdge...PM him if you have to...it is something he does,not something that i have learned.
2. Normal - what is normal? :D hehehe
Well, ideally there should be axis of motion. The easiest is the shoulder - it should spin in the glenoid fossa. Tighten the posterior capsule and it causes excessive translation - what is excessive translation? What is the ideal starting pos? etc etc - this is subjective and based on informed opinion. Ideally though, when you load the GH joint, it accepts the load and doesn't shear thru the joint. In the end, physiotherapy will never be fully scientific because it is an art.
I actually have a Pilates Instructor who is more talented than I at seeing dysfunction. She can't describe it properly scientifically or what she is seeing because she tends to feel what is wrong (she sees it thru her eyes but it transmutes into a feeling in her body that makes her feel "icky"!!) - it sounds all new-agey etc but it is simply how it works for her. I act as a "translator" and listen to what she says and her descriptions and then combine that with what i see and fix the patient...quite often she is right and i have missed something or it is so subtle that it is not easily seen (but she feels it).
A good book to read is "Blink" by Malcolm Gladwell - some people just have good neuronal connections for certain things. LV (my pilates instructor) is good at seeing dysfunction.
I also have a massage therapist (JW) who can feel tension wrapping through the body - things that i don't feel nearly as clearly but when she tells me these things and i examine the patient, sure enough the areas she feels are tensioning are dysfunctional in the way she describes.
All that was just to reinforce what evidence-based practice is...as defined by Sackett himself...paraphrasing here [sorry] Patient experiences, clinical experience and scientific studies all are important in practicing EBP
3. With your finger and shoulder muscle example, careful assessment will show that the finger is more the problem. Also, lets say we know the shoulder is secondary to the finger - do you then leave the shoulder to be dysfunctional? At what point does the secondarily affected shoulder become a problem - does it have to hurt first?
4. Lastly, bias is in everything so just go by how the patient feels. No matter how much i believe the pt's leg is NOT broken, a broken leg will be a broken leg and hopping will not be possible. Proper treatment will result in rapid progression relevant for the condition
Out of time - gotta go :)
Cheers and thanks for the good questions!
Hi
me again...
I have got some extra info on the patient that I am seeing with this bursitis. He has had it for 1 year now.
Most importantly is that the pain presents mainly at night(wakes up due to the pain), but says once he's got up and walked a bit he will be pain free for a few hours again. The pain is described as a dull feeling and can be pin-pointed to the greater trochanter.
The pain is also felt going down the side of the leg(ITB) and then down the outside of the lower leg, but does not go into the foot. This is described as n numbing sensation and does not seem to be originating from the back.
He cycles everyday(spinning) and plans to climb Kilimanjaro in Dec. During activities he doesnt have pain, only at night which tells me theres def a inflammatory aspect to it.
Please help!
Hi,
I went on a tendonopathy course recently and found the Clam exercise very helpful for this condition. I also had a patient who struggled with uneven ground. She improved well with the Clam loaded plus some posture rehab.
Laura Jayne Physiotherapy
Laura Jayne Physiotherapy
Hi Laura
Thanxs for the reply!
Clam exc? You talking about glut med strength exc?
Cherz
Hi Cherz,Quote:
Originally Posted by Fouche
Yes glut med. Doing as many rep until fatigue and increasing the load. Then moving onto straight leg abduction work. Seems to work well. I've only had one patient who it flared up the symptoms so we had to settle pain down first as it was to acute.
Regards
Laura
www.laurajaynephysiotherapy.com
Hi Fouche and Laura,
The strengthening of the deep hip external rotators are excellent...however i think there is some doubt as to whether the clamshell exercises target the glut med...Alison Grimaldi has done some studies and i know she has used realtime ultrasound on the clams exercises and shown that clams preference the TFL, not Glut med.
But really that is a moot point...the most important thing is to make sure that the hip muscles are working together as a team because any overactive or underactive elements will cause the axis of rotation to change and thus cause dysfunction and poor load transfer.
Cheers!