Integration of PT

[BB]

It's been a while since I've been active on this site (sometimes you just need to buckle down in a room with nothing else to think about in order to hammer through some learnin!) and I've been wanting to write on this topic for some time. I can already sense the attacks coming, but here goes.

I'd like to make the case that many mainstream PT practices are very useful, only often mis-used, including those fightin' words posture, strengthening, etc.

Much of Barrett's writing is devoted to describing cultural influence and suppression of the movements that we naturally possess to resolve our issues. Couldn't agree more. I couldn't argue with really any of background on the Simple Contact method, because it is based on solid updated neuroscience. I think that this point expands beyond suppression of movements, and also encompasses the positions and repetitive movements that we are forced to endure as a result of civilization evolving faster than we could physically.

I don't think that our bodies were meant to sit in chairs over long periods of time until our posterior structures become permanently elongated. Or that we were meant to perform certain motions over and over until our tissues assume new lengths. I base my thoughts on the fact that when we address these issues it often resolves our pain, improves our function. I'm not saying that mechanical stress is the cause of pain, but I do think that it can become percieved as a threat by our CNS and therefore painful.

The point I want to make is that our responsibilities as PTs is not ONLY about pain resolution for the present. Once those mechanical issues have been percieved as a threat, that groove has been set. We may be able to start new tracks, but the old ones are still there. If we address these postures, and muscle imbalances, and restrictions then we can reduce these mechanical contributions and move the new tracks further from the old ones.

Now I'll give you that often times the mechanism that resolves the pain is also what resolves these issues I speak of. However, often times tissue change has occured that might require addressing through some of the traditional techniques. The trick is you have to tie the treatment to the problem. Working on posture for the sake of posture may be useless, but working on it because you can tie it to the problem is not.

I'll use an example. A tall person has neck pain, especially with sitting. You take a look at them, and notice that he has depressed shoulder blades. So what? Now you lift them up a bit and he gets some relief. Now you can relate his posture to his problem and look for the the impairments that contribute to that posture. The arm rests of chairs are usually too low for tall people, so they constantly have to reach down for them. Eventually the upper traps, etc., will become over-stretched and this also causes a lot of downward pull on the neck. No big deal until the brain starts to eventually notice and consider it a threat. Now we could do some things to resolve the pain and they could go through Wall's 3 stages of resolution, only to return to that stupid chair and start the process over again. Only now, the brain is familiar with this and notices more quickly. However, if after/during (whatever) the pain resolution we are also addressing the mechanical factors and teaching him to get his shoulders up, there will be less of the things present that contributed to the warnings that were originally sent to the brain.

I think that posture and many of the other PT treatments that are used traditionally get a bit of a bad rap, and I just wanted to start a discussion on it. This may hurt, but I would like to hear what you have to say.

Cory

[nari]

Cory,

This is very useful thread, I think.

With regard to your tall man sitting for hours, say at the computer, it is a situation that we were not evolved to do. It's not all that long since we were swinging about the trees in Africa.
If you educate him about getting his shoulders up, there may be two ways of doing this: fix the armrests on the chair so he can support the elbows (possible) and strengthen the lengthened muscles, or both. Is he going to maintain that elevation of shoulders to neutral by strengthening? In all situations, eg walking for long distances, standing in queues, and so on?

If someone has a thoracic kyphosis and flattened lumbar spine - do you think we can change that? If there is no pain as a result of this certain posture (and for a lot of people, there is no pain)..how do we change it and why would we try to? Is there any purpose, or do you see it as a preventative measure?

I have many doubts about trying to change people's posture, and if there is no pain, we are highly unlikely to succeed, IMHO. If there is pain, then we look at ways of reducing the neural tension.

I wonder if general exercise, strictly nonspecific, would be of most value to achieving better function....

Nari

[BB]

Hi Nari,
I think you are right. Adjusting his armrests would be a great solution and would likely help him a lot. For his sitting problem changing the environment, which was the problem in the first place, I think is the way to go. However, since he has been sitting at the chair for so many years and now does have altered posture, it is also present when he stands, lays down, whatever. If these are not problems for him, then let him have his posture. But quite often, these other positions do become a problem as well. And again, if you can relate the pain to the posture (like for example you change it some way and it makes a difference), then I think you should address it. Maybe all he needs to do is walk with his thumbs hanging in his belt loops, but this may not be realistic if he has to carry things for his job. So, if you find weakness, or shortness that makes sense with the posture, you might have to address it. Also, other movement issues begin to arise. When he raises his arm, his shoulder blade stays down. If it doesn't hurt then so what, but what if it does hurt. Now you've got an environmental problem, that grew into a postural problem, that has now expanded into a movement problem. The brain begins to groove and potentiate motor patterns in the depressed position since this is where it now lives. If you can link it to the pain, I think you should address it. One way would be through a strengthening exercise. If it is done in a way that changes the movement for the better (no pain) then it will strengthen new pathways of movement, and allow those old mechanoreceptors that were sending up warning signals a chance to rest, and hopefully become less dense as the brain begins to ignore the warnings again and remove them from the wall of the nerves.
So, I took that a little farther than I planned to when I hopped back on here.
Oh, the spinal posture question. I think that if you can't tie the posture to the pain, and pain is the reason they are seeing you, why mess with it.
Although, it does raise an interesting question about thresholds. Do you think that the brain might be more likely to hear a warning signal from a shoulder when it is also hearing lots of warning signals from elsewhere, like the immune system, emotions, other mechanical stimuli, etc.

Nice to hear from you Nari!
Cory

[nari]

Hi Cory

The question I am really interested in is: once he has strengthened his traps or whatevers, can he maintain this; or are you saying that it can be maintained by his increased adaptive potential - a phrase I learned from Barrett. In other words, his brain adjusts to the 'new' input and maintains the new posturing, instinctively.

I'm not sure about the answer to your last question on the brain's priorities; how it might prioritise its perceived threats is a good question. Perhaps someone else can offer a reply. I am still tossing (or juggling) the worthwhile effects of strengthening, when the issue is just a weakness. But that's just me....my title given to me is 'neuronut' and I never take much notice of muscle weakness...;) To me, if a (R) quad is 4 and the (L) is 5...and there are no ominous signs....so what?

Cheers

Nari

[JaneS]

BB,
I do like your proposal of brain prioritisation. Since August last year, I haven't had access to all the medical databases. My only recourse to 'current' literature at present is PAIN (am member of IASP) and PubMed and a couple of other sites with articles on free access. These are just my thoughts.

The neuromatrix and limited capacity control system (LCCS) are both likely to be important in prioritising input.
Hypothetically, the brain receives input from all body systems & structures. In detecting input that is different from that which is expected, aspects such as novelty, intensity, predictability are of considerable importance. The cingulate gyrus is believed to have a major part in interpreting new stimuli, 'making decisions' on their emotional importance and determining response (Mosely, 2003).
I can imagine - please note that word - 2 incoming stimuli from different sources. One is a moderate discomfort from, say, the musculature of the back; the other is severe pain from 'somewhere deeper'. Correct me if I'm wrong but I think most patients would be more concerned about the latter because of its intensity and because of the possible involvement of viscera rather than musculature. The LCCS is a psychological concept and permits focus on one input over others. Whether or not pain is one of these, the characteristics mentioned above and the person's previous experience/vicarious experience/knowledge of these features I imagine would determine how the brain would prioritise the input.

I'm not sure what input to the neuromatrix one would get directly from the immune system and how it would 'compete for attention'.

Whether posture correction can be presented in such a way as to occupy the LCCS over other stimuli, I don't know. Such treatment or exercises would have to have a pretty intense or distinct character to take precedence over other input. If the stimulus itself isn't strong enough, perhaps the focus could be on a powerful reinforcer.

Those are just my thoughts on the prioritisation bit of your post.

Jane

[EricM]

Interesting topic Cory,
I think we have to carefully consider why the patient infront of us has come for therapy, and what their goals are. Typically they choose to become patients when they feel as though they have lost the ability to cope with a particular problem. Our aim should be to restore their ability to cope. If this problem is pain, then we should address their pain, in a simple as way as possible and teach them strategies for maintaining a pain free state, or a Nari and Barrett have put it, increasng their adaptive potential. Once this happens the patient may no longer feel they need to be a patient anymore so there won't be any opportunity, or need, to work on other stuff.

Are we oblidged, as health professionals, to alert patients to other issues (fitness) during therapy, if that has not been the reason they sought our advice in the first place?

eric

[Diane]

Working on posture for the sake of posture may be useless, but working on it because you can tie it to the problem is not. I guess it would depend, Cory, on what you mean by "working on" it.

Long before I learned about the neuromatrix and neurodynamics etc., I stopped working from a weakness model, instead worked from a pain/inhibition model that I had cobbled together from osteopathic teachings and by myself. It wasn't much of a leap from that over to considering what peripheral nerves might be trapped in which layer of body wall, and therefore which movements the brain was inhibiting to try to reduce pain, which stirs up its own pain, which leads to more inhibition etc. Inhibition does not = weakness, because as soon as neural tunnels in tissue are relieved/nerves can respire, strength comes immediately back.

I still look at peoples' posture, but not work out what to "strengthen". I especially look at and consider asymmetric aspects of posture. Not so I can go "release fascia", but so that I can work out what area might need some sensory input treatment ahead of something else.

In your example of the tall guy with sloped shoulders and pain, the first thing I'd look at is the lats and serratus anteriors, not so much as "muscles" that are "tight", rather as geographical contractile areas which, through habit, lack of ever pulling up to full height, lack of ever stretching overhead with full awareness and full abdominal breathing, may have long ago clamped down around the lateral cutaneous nerves of the ribcage, and can no longer eccentrically contract/lengthen. The patient may not feel any discomfort there, but if those areas don't slide, the shoulder girdle won't be able to assume its natural antigravity position because it will be getting pulled down from underneath. Of course the "neck" (another geographical location containing many nerves that have to weave through many contractile bungee cords) will complain after awhile. So.. what good will strengthening do? All I see it doing is tightening the body wall or parts thereof up even harder than it already is, and going against the grain of what the brain needs to be able to do in life, which is assist the body to combat a combination of gravity and air pressure while simultaneously staying off its own PNS.

Learning to sequence movement, as in lifting the traps up once in awhile to relieve the neck, is fine for short term, but isn't going to do anything for the hypothetically entrapped nerves down the side of the body under the axilla, which will get strangled even harder by such a move, even if no pain comes from them regionally. Pain from them may be felt somewhere else along the nerve trunk, segmentally, maybe even the dorsal cutaneous branch. Oops, now we've got mysterious mid thoracic back pain. What can you "strengthen" to get rid of mid thoracic back pain, abs?

I think using "weakness" as a lens through which to look at posture when pain arises, is a wild goose chase down a bunch of blind alleys. But that's just my opinion.:)

[nari]

Eric

Are we oblidged, as health professionals, to alert patients to other issues (fitness) during therapy, if that has not been the reason they sought our advice in the first place?

That is a good question, and I don't know the answer. We may say on one hand, leave well enough alone; yet if we feel that their lack of fitness impinges on their wellbeing -I guess we could do some preventative advice. The problem as I see it, what do we advise them to do? jon broached this aspect in another thread a while ago, about exercise/movements to improve fitness at several levels; the thread drifted away as threads tend to do.

So, I would tend not to give advice unless I was fairly sure that it was appropriate for age, etc; and I'm not ever sure about that. Not being a fitness-conscious person has a lot to do with it. I have probably let down any number of patients over the years; however the notion that a person will ask about fitness programs if they want to do them; if they don't want to, nothing I say will make any difference.

In all, I do not see any obligation as a HP to dole out advice on fitness, but am well aware this would be considered as inadequate management.

Nari

[BB]

OK, nice to hear from all of you.
Jane,
I am not familiar with the LCCS, so I'll plead ignorance there until I can read up on it. In my example of thoracic posture as a "danger" input I did not necessarily mean that it was already an area of pain and was competing with another area of pain for attention. What I was thinking of was an area of altered mechanics (thoracic area) sending info to the brain on its status. It may not be enough to make the brain turn its attention to it. But, if the brain is recieving this info, as well as other info on potential threats it may turn up the volume of its reciever and therefore percieve something else as a threat quicker than it normally would. I know when I saw Lorimer Moseley he spoke of Immune responses basically having this effect, which is why we may ache in certain areas when we have an immune response. It changes the threshold of what it takes for the brain to percieve something as a threat that requires action.

Nari,
I do think that a change in "adaptive potential" needs to happen to be effective at making a change in the posture. The new motor groove needs to be one that involves the changed position. At first, a very conscious task, but with more practice (read more grooving, potentiating, etc.) it becomes more instinctive.

This also leads me to Diane's thoughts on strengthening. My version of strengthening is probably not necessarily what you are thinking (weights clanging in functionally irrelevant contexts). Since pure muscle strengthening takes quite a while to occur, I think that most of what we see in strength gains is a result of neural recruitment. I like to think of strengthening motor patterns and improving patterns of recruitment. This can be done effectively with resisted movements if they are done in the context of the new movement pattern. The resistance increases the input and makes the brain "hear" the new pattern louder. Again, grooving and potentiating.
Diane,
Your description of the cutaneous nerves brings me to a big point...in a minute. Again I think you treat what is relevant. A rational area to also address would definately be thoracic spine, rib cage, all their corresponding neural contributions, etc. We could easily integrate some feldenkrais type movements, neurodynamic movements, etc. to all of this. One of the big reasons I wanted to discuss this topic is that I think we need a more broadly encompassing context with which to examine what we do. I think that if we learn to discuss such things in contexts eachother can relate to we will discover/be able to offer explanation to more reasons of why lots of things are successful for those in pain, and be more successful in figuring out why other things are not. Integration.

Cory

[nari]

Cory

You are right....we do not integrate very well.

But most of the integrated concept of neuropsychoimmunology is relatively recent; and I think one of the factors which keep PTs going slowly towards change is the scarcity of clinical applications. For some, this must be overwhelming; considering the multiple variables that present in almost all patients we see with a complex problem.
David Butler, Michael Shacklock and Barrett have satisfied some of that problem admirably, but when I last looked -their techniques are not widely used by PTs, even when sensitivity stares them in the face.

I also think that many PTs are concerned about the psychosocial issues which appear in the history; and this, unintentionally, creates the great divide. PTs look after the physical aspect, psychs and social workers tend to the emotional aspect. It seems to be hard-wired.
Very basic CBT is not difficult to learn, and courses are run here for PTs. Until we understand the basics of CBT or some other approach, and learn how to talk and relate to the patients with respect to their psychosocial issues, something will be missing from our PT approaches.

I'm not talking about treating, in the psychologist's style - just using the right language and so on. This is not a popular line of thinking, and with SC it is not necessary - but how many PTs consistently practise SC?

I guess I am making prejudgements here; but these are thoughts which I have pondered over for some years. So if one is using traditional physiotherapy, we need to integrate a huge amount of knowledge into good clinical practice. If we consider the CNS in everything we do, bar none, that is a start. It doesn't mean we perform neurodynamics on everyone, just as SC is not appropriate for everyone PTs meet up with in the clinical scene.

Chris, how many PTs do you think would perform routine upper and lower limb tests on all upper and lower dysfunctional presentations? Even prior to measuring ROM and that stuff? I would guess, very few....

Pardon the rant.:) :)

Nari

[Sandra]

Integrating techniques is what I learned in PT school. The names have changed over the years, and I am somewhat out of date despite my efforts at staying current in research. There is always some 'new' approach in the con-ed literature that on closer look is a 'new' synthesis on old techniques.

NDT was my start in therapy - I have layered many different manual therapy techniques over that base. I joined here to take a look at other views of treatment and am happy to see a stong neuro approach.

I believe all movement and problems must be looked at in function in the clinic, to include training the patient in how to continue to maximize function independently at the end of therapy.

I am going to be lurking more often that not, until I feel a bit more up to date on the references and articles I see listed.

[Sandra]

"Chris, how many PTs do you think would perform routine upper and lower limb tests on all upper and lower dysfunctional presentations? Even prior to measuring ROM and that stuff?"

Nari: I would hope ALL do - I expect nothing less from the students I train.

That should be part of routine screening.

[nari]

Hi Sandra

Welcome to the board. I'm pleased to see another 'neuronut'; there are quite a few of us here....

I'd be interested what country you are from; where I am, neurodynamic tests are done as a sort of afterthought, if all else hasn't turned up much. I am speaking of course, very generally, more of a trend than anything else. I don't think the ULNTs, for example, are then turned into a treatment program if they (or one, or two) are found positive...they tend to be regarded as 'tests' only.

Feel free to post even if you do not have accompanying references at the time. Clinical experience is still worthy of mentioning...

Nari

[Sandra]

Thanks - I am in the US but have moved around a lot. I went to school in Oregon with a wonderful NDT instructor as the head of the program.

My neuro techniques may be different - based on neural gliding (which appears controversial in the research and may best have a different name), and books such as Tunnel Syndromes and various articles.

I will check back tomorrow as I must carry on with my mom duties.

[bernard]

Hi all,
Nice to see you again, Cory,

I have many doubts about trying to change people's posture, and if there is no pain, we are highly unlikely to succeed, IMHO. If there is pain, then we look at ways of reducing the neural tension.

I know that it is a recurrent point of dispute with some moderators about "the pain and posture relations" but I think there is an explanation:

1/ human beings are individual and all different.
2/ human beings share common properties (walking, eating, breathing...)
3/ All these functions are common but differ greatly if you look at some slight difference.

Of course, if one try to say "posture and pain are related" it will fail because the relation is only personal and individual.

But if you refine your definition in this way : All humanbeings have a personal posture which enables personal mechanical limits and when these personal limits are reached then this individual may experience pain that is a subjective experience.

Reducing a neural tension is changing some way a posture, perhaps on avery light manner but in direction of a better one.

[BB]

Hi Bernard,

I absolutely agree. Everyone is different, and there is no one "right" posture for everybody and one function may affect 2 people very differently. An example would be a very tall person who sits in a chair all day, everyday, and a very short person who does the same thing. They may both end up with back pain, but for very different reasons.

Cory

[Eddy Maillot]

Sandra,

Thanks - I am in the US but have moved around a lot. I went to school in Oregon with a wonderful NDT instructor as the head of the program.


My clinical experience and continuing education are a big dish that has been flavored with many orthopedic and neurological patients and courses. In terms "treating any pts -whether they were ortho, peds, or neuro pta", my favored spice was the NDT approach, before, during and especially after having taken the 8 week peds course. My colleagues who partook in the clinical meal didn't and probably still don't understand why I was so adamant to boldly vociferate that most if not all "ortho pts" are to me neuro patients. I am more than ever convinced of that. Are you still using your NDT training?

Eddy

[nari]

Sandra

I use neural glides, or sliders as they are sometimes called in all their infinite combinations depending on presentation. I like them because they are so easy to do and the patients can do them at home with some education and, of course, the mandatory precautions!


Eddy

most if not all "ortho" patients are to me neuro patients
Music :note2: :note: :note: :note2: to my ears!

If only all PTs see it that way.......

Nari