Did therapy help your knee pain? If no…continue to read. 

Did therapy help your knee pain? 

“Knee osteoarthritis (OA) is one of the leading causes of pain and disability worldwide”

This is an indication of how prevalent this condition is in the world. Arthritis is seen as a byproduct of aging, but this doesn’t mean that it directly causes pain.

“…exercise intervention has been shown to be efficacious and is recommended in multiple guidelines; however, its treatment effect has been reported to be modest.”

Everyone can benefit from exercise, but the extent of the benefit for patients with knee pain may not be that “miracle” that people expect.  

“Although the statistical effectiveness of exercise for knee OA has been clearly demonstrated and may be equivalent or better than commonly prescribed medications, the effect on pain reduction and function remains modest.”

Exercise is a powerful tool or at least among the most powerful that we have now. In saying this though, it is not a magic elixir.  

“The MDT approach has been extensively used to classify and treat patients with spinal pain. Studies have shown the MDT approach to be valid, reliable, able to successfully predict outcomes and associated with decreased lumbar surgery rates, pain, and disability.”

If this doesn’t sound great, then I don’t know what does! MDT (Mechanical Diagnosis and Therapy) is a specific assessment and treatment style that Is not taught in school. One must go through advanced courses and take a test to say that they are competent at using the method. Ask your therapist if they have taken any courses in the method and if they have achieved the certification through the Institute. This is the only way to determine if the therapist that you are seeing is competent to utilize the principles of the system.  

“The most prevalent and well-studies MDT subgroup is the ‘derangement’ classification. This classification has been described in all joints and has been associated with a rapid response to specific end-range exericses…”

Would you like your symptoms to rapidly improve? Who wouldn’t? Roughly 40% of patients with knee pain may have symptoms that respond rapidly to a single exercise. Turning off pain doesn’t have to be difficult. In many patients, it only takes a single exercise to reduce or turn off the pain. This has to be followed-up with a constant assessment in order to determine which exercises the joint will tolerate at a specific point in time in order to ensure that the symptoms do not return when not in the clinic. There has been a lot of research in the medical world regarding Low Back Pain, but this article is the first that I have seen using the same principles for osteoarthritic knees.  

“…significant treatment main effects were present for all primary outcomes. The MDT derangement subgroup had improved scores at 2 weeks and 3 months compared to the MDT nonresponder subgroup for all primary outcomes”

This is huge! This sentence essentially states that doing one exercise is more beneficial than doing many for a small subset of patients. Now for a little more information on a derangement. If there is one exercise that can greatly improve your pain, then there will be multiple exercises that either have no effect or make the pain worse. If your therapist is not at least looking for and ruling out this preferential exercise or direction of movement, you may be in therapy for a longer period with a longer list of home exercises. These exercises may or may not have a positive or negative effect on patient’s whose symptoms are rapidly reducible.  

“The physical therapists were credentialed in the McKenzie system, and results may not be applicable to non-McKenzie-trained therapists.”

This sentence stands on its own. Anyone claiming to use a method should at least be trained and credentialed in using the method. In the Joliet area, there are only two of us endorsed by the McKenzie Institute to utilize this method.  

 

In short, this study was performed on patients waiting to receive a total knee replacement, which means that they were shown to have severe arthritis on an X-ray. The patients receiving McKenzie-based treatment outperformed those receiving traditional evidence based guideline therapy and those that received no therapy. Seek out an MDT trained clinician if you are experiencing knee pain.  

 

I can be found at:

Functional Therapy and Rehabilitation

903 N. 129th Infantry Dr

Suite 500

Joliet, IL

815-483-2440

Post 79: Movement Impairment System and hip pain

Post 79: Hip pain
“Hip pain is a common complaint for which people are referred to physical therapy. The prevalence of hip pain in adults over the age of 60 ranges from 9.7% to 19.2%”

Hip pain…think of a pain that is around the groin region that radiates down to the knee (but on the front/inner part of the thigh). Sometimes pain in the buttock could come from the hip, but other areas that could cause buttock pain should be ruled out first. For instance, the SI joint can also cause buttock pain, but if the person is elderly it is probably not the cause. The spine could also cause buttock pain, and in a majority of “pains in the asses” that I see are coming from a spinal referral.

Hip pain is not the most common ailment that I see in the clinic, but it is not rare either. There are a lot of structures surrounding the hip that are innervated (have a nerve source), which means that there are a lot of structures surrounding the hip that could cause pain. I don’t think that our job as therapists is to find the exact tissue that is causing pain (although there are some patients that just need to know), but our job is to classify the symptoms and place the symptoms into a puzzle that makes sense for us. We do this mostly by pattern recognition (at least for therapists that have seen patterns over his/her careers), but we may also have to do this by using the HOAC method (smart way of saying: “give it a shot and see if it works”).

“Abnormal or excessive loading of the hip has recently been recognized as a potential cause of anterior hip pain and subtle hip instability”
I partly agree with this. For those that don’t know me well, I am certified in Mechanical Diagnosis and Therapy, which was proposed by Robin McKenzie in the 1960’s. He proposed a syndrome called the postural syndrome, in which healthy tissue, abnormally loaded, will create pain with the possibility of becoming a dysfunctional tissue over time. In short, I agree with the above statement.

“Femoracetabular impingement is present in 10% to 15% of the population…symptoms are commonly manifested as insidious groin pain.”

I had to look up the three different types of FAI (the long words from above). This means that the ball and socket portion of the hip is not working appropriately. When thinking of a hip, think of a golf ball and tee. The ball is the ball portion at the top of the thigh. When it is round like a ball, it can spin on the tee without falling off. Now imagine that your tee is a little deeper and larger and can encompass the ball. This portion that would encompass the ball is the acetabulum. It is a piece of cartilage that makes the tee deeper so that the ball can sit in without falling off the tee (think dislocated hip if the ball falls off of the tee). So one type of impingement is if the ball is no longer round, but shaped in a different fashion that makes the ball a little bigger on one side. This would cause the ball to pinch on the acetabulum with certain movements (more on this later).

Another type of impingement is when the tee is malformed. This could cause the tee to pinch on the ball, also causing pain.

Either way, groin pain is the chief complaint typically seen in the clinic.

“Combined hip flexion, adduction, and internal rotation movements (FADIR) along with maximal hip flexion most commonly replicates the pain…catching, clicking and feeling of ‘giving way’.”

Picture a little kid doing the “W” sit. This is what the above sentence describes as FADIR. I know…you’re thinking I can’t do that any more…GOOD! That’s not good for you anyway. Now close your eyes and imagine yourself going up stairs. When you go up stairs, do your knees collapse inwards? Don’t answer yet! Imagine yourself slowly sitting down onto a soft couch (you know what I mean…the ones that you sink down into). Did your knees cave in? DON’T ANSWER YET!! Finally, imagine that you are getting up off of the toilet. Do you have to lean far forward or better yet, rock forward and backwards a couple of times in order to get up off of the toilet? Now you can answer. Did you answer yes to any of these? If you don’t know, that’s alright, my imagination sucks also. Go try it. If you have these things happening, YOU HAVE A PROBLEM!

The first step is simply admitting that you have a problem. Unless you admit that you have a problem, you’ll never get to asking for forgiveness from your hips and knees. I thought that the analogy was good.

Anyway, when the knees cave in, this is a poor position for the knee and the hip when in a hip flexed (knee closer to chest) position.

“Hip joint forces are altered by hip joint positions and changes in muscle force contribution”

“I love it when a plan comes together” Hannibal Smith from the A-TEAM.

This describes another of MDT’s syndromes: the derangement syndrome. This is simply a change in the normal resting position of a joint. It may cause muscle inhibition. This a lay term for “shutting down”. On a side note, there has been major debate on Facebook for the terms used to educate society. For instance, in Supple Leopard, Dr. Kelly Starrett describes a muscle as turning off (he means that it is not working to its fullest potential), but some therapists have a hard time with this phrase. This is why I used the phrase “shutting down”. Maybe they won’t have a as hard of a time with this terminology. I don’t know, but if you don’t get the point…please ask.

When a joint’s position is changed then the muscles that act on the joint will change also. Quick example: my dad used to take me out to plant trees in the forest every year. We would tie the tree down using 3 stakes in order to ensure that the tree grew straight. Now imagine if we used the same 3 stakes, but before driving them in, we placed the tree at a 45 degree angle to the ground. (Think leaning tower of Pisa/Pizza). If we pull on the strings in each scenario, there will be a different outcome on the tree. In one, it will be stabilized and in the other it will fall over even further. This is what happens when a joint is altered in its position. When the muscles contract (the strings are pulled), the joints movement will be altered from normal.

“The 2014 clinical practice guideline on nonarthritic hip joint pain recommends interventions such as patient education, manual therapy, therapeutic exercise, and neuromuscular education, but the strength of the evidence for all of the recommended interventions are at the level of expert opinion”
This is important for all of the PT students that may read this blog. We have entered a world with buzzwords such as evidenced based practice/medicine. We are supposed to be using the highest form of evidence or using “best practice” when treating patients. For this ailment, nonarthritic hip pain, the best we got is a bunch of people coming together to give us an opinion. Granted, the people are really smart, but for a profession that is trying to sell itself as “movement specialists”, we should have more than opinions to sell to patients.

“However, Byrd and Jones report that FAI is not necessarily a cause of hip pain; it is simply a morphological variant…”

Wait… You mean to tell me that having a problem on an image, such as an x-ray or MRI does not correlate to having symptoms?! Obviously I jest. An image alone does not indicate a problem for most musculoskeletal problems. The image must be correlated with clinical signs and symptoms. A person without signs and symptoms is healthy, as some problems noted on an image are correlated with age related deformities. Think of this as a wrinkle. For instance, as we age our muscles go from the texture of filet to the texture of beef jerky. Things start wearing down. We are the ultimate machine, but we have yet to figure out how to keep the machine from breaking down.

“While physical therapists can not change the morphology of the hip joint, they can address movement impairments, muscle strength deficits, and certain aspects of joint range of motion to decrease stresses on the anterior hip joint”

I will not make your bones longer or shorter. I will not change the depth of your joint capsule. I will not make you into something that you’re not. But what we can do is address the issues that you have at that point in time, that aren’t structurally unchangeable. Here’s an experiment I want you do: squeeze yourself into the smallest suitcase that you have and I want you to hang out there for 5 hours and then try to get out. It doesn’t feel so good. I didn’t change any of your structures, but I probably created symptoms. Not all symptoms are related to the structural change, and not all structural changes related to symptoms.

“…movement system impairment syndromes described by Shirley Sahrmann,PT, PhD. The movement system impairment approach places less emphasis on identifying the source of the symptoms and more on identifying the pathomechanical cause.”

I’m always reminded of an old research study, I don’t remember the author, when we give you a diagnosis based on pathoanatomy, we (medical professionals) are right 10% of the time. I can’t specifically tell you which structure is causing your symptoms. What I can tell you is you have symptoms when you move. Maybe if we move a different way your symptoms all go away. It’s my job as a therapist to understand the different ways that movements may affect your symptoms.

“27-year old female…left anterior hip pain July 2014 after doing Miri-directional lunges…continued despite pain…after one week discontinued the multi-directional lunge but continued with deadlifts, squats to 90 degrees…sprinting/walking interval training prior to her injury…discontinued in August due to pain. Before July…she was pain-free…did have clicking, snapping and pinching in both hips…main goal was to return to lifting weights while doing squatting and lunging movements without pain.”
The biggest thing to take from the above is that the patient is active. She is not a couch potato.. This patient is the perfect patient to come into the clinic. I love trying to help these patients get back to their active lifestyles. This is the patient that I am going to go over and above in order to return them back to the gym. I AM A MEATHEAD. I see that as a term of endearment.

“…stood with swayback posture and displayed increased hip medial rotation on the left compared to the right… Had increased pronation bilaterally as well as a positive “too many toes” sign… Range of motion of the lumbar spine was normal and pain-free… Adequate hip flexion range of motion during forward bending but the majority of the motion came from the thoracic and lumbar spine… positive Trendelenburg sign bilaterally.”

 Essentially, description is that of a person with poor usage of the hip muscles and a lazy stance. Could indicate some tightness and she stands with the swayback, but it also may mean that she needs better motor control and a better understanding of what appropriate standing posture actually is. Just from the above description, she seems like many of the females that I see in practice.

“During single leg stance, the patient displayed contralateral hip drop during single leg stance bilaterally, increased hip medial rotation on the left, and decreased balance on the left… Able to squat just passed 90° of hip flexion, but displayed increased forward trunk flexion and reported pain at and range. Hip flexion range of motion at her and range squad was 104° in the flexion range of motion was 92°.”

What this is describing is a partial squat. She is unable to go to full depth because of pain. She also has significant weakness in her hip muscles as noted during single leg stance. If you stand on 1 foot, and you notice your opposite pocket falls significantly compared to when you’re standing on both feet, then you probably have a problem in your hip ability to generate force. Sometimes we’ll see this when a person, specifically female, is walking away from us. This looks like that infamous hip wiggle. Not that I’ve ever watched! I love you babe.

“patient displayed overall hypermobility throughout the exam and had 8/9 Bieghton score for increased ligamentous laxity.”
This is otherwise known as the contortionist scale. If you could dislocate your joints at will, they probably aren’t very stable.

The intervention was actually pretty good. The authors describe meso and microcycles for endurance and strength training. This takes me back to my days as a personal trainer through the International Sports Science Association. I have yet to hear physical therapists discuss mesocycles, until this article. Essentially, they placed the patient on a progressive 2 week cycle that built upon itself over the course of 6 weeks emphasizing core stability, endurance exercises, and the addition of plyometrics.

“At the end of 6 weeks, a second reassessment was conducted. The patient stated she was now able to perform a full squat.”

Nuff said!

This is a good article because it describes that patients can improve rather quickly from functional limitations and pain when issued the appropriate interventions. One thing to note from the article is that although it took 6 weeks to improve, the patient was not treated frequently due to her schedule. The idea that a patient needs to be seen three times per week for four weeks is a tradition that needs to be questioned. As a therapist, I must place my patient’s values and health above my own needs. This is one of the core values of our profession. When I start treating you like a dollar sign, then I no longer am treating the patient according to their needs. Don’t get me wrong, some patients may need to be seen 3 times in a week, but these are few and far between in our clinic.

If you have an questions, comments, concerns or good jokes please feel free to let them fly. I can be reached through comments on this blog, @movementthinker on Facebook or at my personal page on Facebook.

Vince Gutierrez, PT, DPT, cert. MDT

Excerpts taken from:

Smith A, Brewer W. Management of Anterior Hip Pain Using a Movement System Impairment Approach: A Case Report. Orthopaedic Physical Therapy Practice. 2016;28(4):226-235.

 

Boys…put your balls away

MORAL: Boys, put your balls away. Nothing more to add

 

  1. “Developing core strength has been emphasized as a valuable component in general and sports conditioning programs in addition to active rehabilitation programs for individuals with low back pain (LBP).”

 

What is the core? We all see the late night infomercials talking about core strength and see people with washboard abs. Is this core? Not exactly. Picture this: the strike zone in baseball. Not the MLB, because that strike zone is almost non-existent, but little league baseball. The old middle of the thighs to the letters of the jersey, that’s the strike zone. Now, picture all of the bones and muscles that are in this area. Do the same thing for the side of the body and the back of the body. Most everyone neglects the back and sides. We all want that beach body you know. Unfortunately, that beach body is all show and no go.

 

Core stabilization is more of a communication thing than an Incredible Hulk thing. The muscles of the “core” (strike zone) have to be able to transfer the amount of force that your legs are generating and apply it to something that your arms want to do. All of the body by Jakes or ab rockers won’t get you there. They will do a great job of strengthening your target muscles for that specific exercise, but they won’t do anything for making you a better athlete or better person for that matter.

 

  1. “Numerous studies have placed individuals on trunk exercise programs that in turn resulted in a greater increase in endurance and decline in reports of LBP episodes”

 

If you are a couch potato, than doing anything may be better than doing nothing. If this is you, then stop reading because the ab rocker is waiting for the next set. If you aspire to more than just couch potato, then doing unweighted trunk strengthening exercises may not be enough for you.

 

  1. “It is apparent that training while under unstable conditions does increase the activity of these (trunk) muscles”

 

Enter the Bosu ball or the Swiss Ball. This one statement has created rooms of balls in gyms and has spawned people marching in place while sitting on a ball in the physical therapy clinic. If you are one of these people and really think that you are being uber effective, then this article may be offensive. PUT YOUR BALLS AWAY!

 

But I can already hear you say: “increased activity” blah, blah, blah. Look, being busy is not the same as being productive. Increasing activity does not lead to increasing strength, unless you are increasing the load as well. When I say load, I mean weight. The kind of stuff of the legends of Paul Anderson, Franco Columbo, Kaz (he is so legendary that he only needs to go by his nickname). Look these people up. I can say with certainty that they weren’t training on balls.

 

  1. “Behm et al had subjects perform various trunk-stabilizing exercises with stable and unstable (Swiss ball) conditions. Results indicated that the abdominal stabilizers, LSES (back muscles) and ULES (upper back muscles) exhibited significantly greater activity with the unstable conditions. The 2 most effective exercises for trunk activation were the side bridge and superman”

 

Again is you are weak than doing anything is better than doing nothing. If you have weak muscles, then lifting a spoon is difficult and your muscles will get activated. “Only the strong survive.” I don’t want to activate, I want to get jacked. Why? Because someone that is strong will be able to get their butt off of the toilet at the age of 80, without the use of handrails. Someone that is jacked will not have difficulty getting off of the floor and being a stereotype like on the commercial. People…it is not about turning on muscles. I can turn on my butt muscles by squeezing my ass cheeks together. Activation does not equal functional and surely doesn’t mean strong.

 

The Swiss ball is one of the worst things to be introduced into our profession. That’s right…I said it! We as a profession spend way too much time training unstable situations when the patient needs to get stronger. I can hear the PTs arguing now: “What about balance patients? What about patients that need to walk on unstable surfaces?” Great! Do Swiss ball stuff for this purpose, but stop selling the unstable training as a means to get stronger. I am saying “I AGREE WITH YOU”! Ok, now get rid of the Swiss ball for all other purposes. We are doing the patient a disservice. The logic made sense years ago, but the research just isn’t there.

 

On a side note: I want as many patients as possible to read this blog. This way the patient can be armed with facts to go into the PT with in order to question the activities that are being performed in the clinic. If I can’t give a good reason for why I am doing what I am doing, then fire me! We are in a day and age in which results will be the driver of our profession. This is already starting to happen with “bundled payments for total joints” ( I highly suggest that you educate yourself on this also. I may or may not write about this soon). We need to make sure that as health professionals that we continue to get smarter and better at what we do. Patients need to continue to educate themselves about their health for two reasons 1. IT’S YOUR BODY! 2. You will challenge your health care provider to either get better or get lost.

 

The two most effective exercises for trunk activation are the side bridge and superman, said no strongman, crossfitter or strongman ever!

 

  1. “Swiss balls have been incorporated into strength training programs on the belief that a labile surface will provide a greater challenge to the trunk muscles, increase the dynamic balance of the user and possibly help to stabilize the spine in order to prevent injuries”

 

Coming soon: Humans on Mars. Same kind of statement. The above quote starts by talking about beliefs. Look, are we a faith or are we a science? We can’t have both. If we believe something to be true…it also has to be true. For a long time, the world was flat. We believed it to be true, so it was true. We have come a long way since Galileo. We actually have to test our beliefs to see if it is worth using.

 

I am a meathead. Swiss balls are fun to play tug-o-war or work on balance (such as advocated by Paul Check), but they are not good for building stability. To be stable is to be the opposite of mobile. We need to make our trunk opposite of mobile. We can do this by resisting a heavy load.

 

  1. “…one must ensure that their training regimen incorporates training specificity”

 

Joe Weider. The name brings back memories of the old Weider barbell sets sold at Sears. We had the concrete filled plastic weights. My how far we have come…and yet the same principles still apply. If you want to get better at throwing a punch, don’t work on kicks and if you want to be a better swimmer, don’t practice skydiving. If we want to be strong and stable (i.e. immobile), then we need to practice on being strong and stable.

 

  1. “The practical application of training the trunk stabilizers from a supine or prone position may not transfer effectively to the predominately erect activities of daily living”

 

If we pair point 6 and point 7, then there’s only one real reason to practice exercises in a horizontal position…you know what I mean (wink, wink).

 

Anyway, the new buzz words are functional fitness. The above statement is essentially saying that doing exercises that are not similar to what you would do during your day may not be functional. You hear the old joke about 12 oz curls, yeah I’ve heard it too. If all you do all day is drink grape nehi, then you don’t need to do anymore than that. It’s functional for you.

 

  1. “Perhaps a combination of relatively high-intensity resistance using free weights (light to moderate instability) can provide greater activation than the very popular instability exercises commonly used today”

 

DUH! Anyway, the authors are finally talking about a quantity of activation. There is no doubt that lifting a beer bottle will activate your arms and trunk muscles, but I’ll take the guy that is lifting kegs for fun if I was a betting man.

 

  1. “The 80% 1RM squat exercise exhibited significantly greater LSES EMG activity than all other exercises…exceeding the body weight squat, deadlift, superman, sidebridge exercises by 56, 56.6,65.5 and 53.1% respectively”

 

When compared to dead lifting, side bridging and superman, the squat is THE KING OF ALL EXERCISES! For lumbar spine muscles. Hear that all you bird-doggers! Hear that all you supermanners! There is nothing better than loading a heavy barbell with 45 pound plates and squatting down and standing up. I miss the sound of the 45 pound plates vibrating next to each other when you walk the bar out. I use bumper plates nowadays. Not as much testosterone as the steel, but a hell of a lot safer for my garage floor if I have to dump the weight.

 

Put it into perspective, this exercise is 50% better than most popular exercises. Everyone can squat. Everyone has to get off of the toilet. If you don’t, you will end up in a home because no one wants to help you off of the toilet and wipe your behind for free.

 

  1. “The 80% 1 RM deadlift exercise exhibited significantly greater ULES EMG activity than all other exercises”

 

There is a reason why powerlifters have such thick backs. They specialize in the 2 exercises that work both the lower and upper lumbar muscles.

 

  1. “…it may be unnecessary to add calisthenic-type instability exercises to a training program to promote core stability if full-body, dynamic, upright exercises are implemented in the program”

 

Time to turn off the t.v. Stop buying all of the infomercial crap and just get up off the couch…now sit down…stand up…sit down…stand up…sit down. Now go do the same thing while holding a can of soup. You are now stronger than you were yesterday.

 

Excerpts taken from:

Hamlyn N, Behm DG, Young WB. TRUNK MUSCLE ACTIVATION DURING DYNAMIC WEIGHT-TRAINING EXERCISES AND ISOMETRIC INSTABILITY ACTIVITIES. Journal of Strength Conditioning Research. 2007;21(4):1108-1112.