new boy seeking opinions

[lloyd]

My colleague asked me to have a look at a patient with her and I thought that you folks would surely have some useful input to make.
I’ve only seen him once for half an hour and not done any physical assessment but here’s what I’ve got so far.
28 yr old male workaholic with long term intermittant back pain. When he was 16 he had three incidents in a year –cant remember what the first two were but the third was playing rugby and ended up with him in hospital on traction for 3 weeks with right side lumbar and and posterior leg pain.having an epidural which he remembers them having afew goes at because they couldn’t get it in. An MRI scan showed a prolapsed or bulging disc- he’s not sure of the details mostly it was relayed through his parents. Seems he was also told he would always have trouble with it.-The bone was pointed at him you could say.

Currently and it seems it been so mostly since then- he can be pain free for sometimes a couple of weeks with maybe the odd little twinge (same pattern as original incident) ,painful for a few hours when he turns or gets out of car –any old movement seems to do it . Then for no apparent reason he’ll get it much worse which means he’s in’ agony’ for up to a few days although the intense aspect last for maybe an hour when he’s flat on his back. Pretty soon after that despite agony he’s back at work.
Plenty of unhelpful cognitions and fear avoidance behavior particularly of forward bending- pathological dislike and had an intense episode a few hours after Kate my colleague had him do some pelvic tilting in 4 point kneel and a very gentle forward bend in sitting which at the time felt okay although he believed he’d done to much. He says it feels like something comes out and jabs the nerve.

Also interestingly he can certainly turn his pain on by eating a full meal and off by evacuating. This gets him lots of weird looks from doctors but I assume is due to central sensitization and activation of his pain neurotag via pressure on any number of autonomic ganglia or the lumbosacral plexus itself.

So my questions are- examination wise anything particular to look at other than neuro dynamics and neuro( I think that’s clear but not sure ).
Given that his pain seems pretty on /off rather than that kind of ongoing variable level of typical chronic pain where’s the pain being generated.? Do peripheral aigs behave like that. His central processing is obviously disordered but does that mean also dorsal horn changes . How much of the neurotag is likely to be cell changes which I imagine as more difficult to shift and how much simply patterns of activity that can be fairly easily taped over.

Anyway I could keep rabbiting on but I’m sure you’ve all goy things to do so I can add more later if necessary.

thanks folks
regards lloyd

[Diane]

New boy lloyd, welcome.
It would be helpful (probably) to know a bit more -
1. What sort of work does he do? (I.e., what are his normal unconcious extero/proprio/interoceptive inputs?)
2. Where does he get the feeling of the "jab"? (I.e., which of his peripheral nerves might be habitually hypoxic/mechanically irritated, and contributing to the overall pattern?)
3. What sort of positions does he choose to lay or sit around in to relax when he feels "good"? (I.e., see #2)
4. What are his sleeping positions? (I.e., see #2)

Interesting that using his GI tract helps with the pain. There might be some kind of mechanical aspect or it might be central - it seems all roads into the nervous system lead to the insula.

Please "rabbit on" more. :)

[lloyd]

Dear Dianne,
thankyou Your Prolificness. In my only other ever post on noi you were also ist to reply.
Partial answers to most of that. I will find out next visit and or see if i can get Kate to answer those as she's seen him a few times. He's an office man and doesnt seem to relax as far as i can tell .Pionted to his right lower lumbar jabbing and get sciatic distribution referal.
Off into town (plymouth) for a very very rare trip to see if there's any clothes left on the sales rack.My rack looking empty and there's a valentines party tonight.:love::shade:

[lloyd]

shopping:thumbs_do party:thumbs_up :note: :) .
no replies :cry:
:rose: for the next comment

:love:lloyd

[BB]

Hi Lloyd,
Sorry for the lack of answers. I was waiting until more info came.

interestingly he can certainly turn his pain on by eating a full meal and off by evacuating.

This would have me a bit concerned about a non-mechanical issue. Especially if it were a newer presentation. Could be a sign of gall bladder issues. Sounds as though he's been checked on it by physicians. Could be useful to see what they've tested regarding this. Does his pain tend to come on/leave at certain times of the day? What is the nature of his pain at night?

where’s the pain being generated.?

It is being generated centrally as an output of the brain. Where all in the periphery is it being stimulated is pretty difficult to answer even with a lot of information. Although, you can figure out where it's effects are manifest in the superficial layer with some thoughtful palapation. Diane will be able to help here.

An easier question to answer is HOW is his pain stimulated. Is his pain mechanically or chemically stimulated?
Does his pain respond to movement? You said he dislikes flexion. Is this because he is afraid of his disks or because it increases his pain?

How much of the neurotag is likely to be cell changes which I imagine as more difficult to shift and how much simply patterns of activity that can be fairly easily taped over.

Any change in sensitization will cause cell changes. There are short term changes which change quickly (and this is the density of ion channels in the neuron wall), and there are long term changes that don't (and these are the changes in gene expression and long term potentiation). I would think that these are likely happening at the synapses first, and the DRG (where cell bodies live and therefore where changes in gene expression will be initiated) second.

[lloyd]

THanks Cory, you get the :rose:
It seems I ve got more first visit to do let alone second.
I'll gently push Kate (my spiky haired work mate) in this direction I'm sure she's got answers for most of those questions.

Ive got a reading list as long as both arms. there is a veritable smorgasboard of goodies on this site alone. Seems i've been an ostrich for
to many years now.

Praise to the ectoderm :rainbow:

good day youall
Lloyd

[keery]

sorry if i would seem out of subject but those boys are so cute!!!!!!!!!!!!!!!!! omyy i'm falling in love......


[i'm not into any medical fields] but maybe he could eat more calcium for the bones and be more relaxed? you do mention him being a workaholic... and sooo young.

[ginger]

Lloyd, you will find a lot to enjoy at this site, not the least of which will be the diversity of opinion and alternatives generally about how to apply thinking to problem solving. In the situation you describe , my first observations would be to consider spinal movements. In the protected, tight,( learned and automatic) state of affairs this patient survives in, there will be some obs you can make that are just about certain to be true. First among these will be that the lumbar facet joint movements will be compromised. My own way to assess this is most often direct,, that is to feel those movements, and of course ,resistance to movements , by attempts at passive movement. In other words , mobilise.
Over many years I have learned to employ my hands to determine the state of mobility of spinal joints and to consider the likelihood of improvements, both mechanical and neurological , on the basis of facet mobility. Invariably in cases where spinal pain and refered events are a feature, there will be a state of hypomobility to spinal facet joints. These joints respond to protective tightness ( of muscle ) by a cascade of local efects that result in both the maintainance of that protected state and the ongoing, incremental advances often including those you have described in this patient. From a practical perspective , most of the protective events , and their corrolory, referred pain , can be turned off with manual therapy.
In my own practice , I find that specific attention given by continuously mobilising facet joints achieves what often cannot be achieved by alternate means. That is , to restore a non painfull , non protected state to the spine. By doing so it becomes clear that a great many musculoskeletal pain and behaviour problems, such as this mans sciatic etc pain , are best explained not by reference to pathological states such as destructive lesions, but by a much more ubiquitous element in spinal causalgia, protective responses .
In the direct business of a hands on approach I have yet to learn of a more immediate, lasting or effective ,safe method ,than to provide passive movement to facet joints. The method I have pioneered and taught for many years is known as Continuous Mobilisation. Should you wish to learn more of the method , I recommend you go to the rehab edge site and read the posts in the manual therapy section there.
All the best.

[Baecker]

Hey Ginger,

Sorry to disturb the thread but do you also practice your continuous mobs on a patient with severe radicular pain caused by disc herniation? I am just wondering? And if yes I found that any mobs, even very light and gentle ones in that segment (with the disc herniation) seems to cause often more pain, what about you?

Looking forward for your reply. Btw I used your continuous mob on a patient with adhesive capsulitis not touching the shoulder and he is doing pretty good. :thumbs_up

[ginger]

Hi Baecker
Yes I do use CM in cases where there are known as well as unknown disc pathology. The method provides a means to turn off protective events and associated somatic referred pain. CM is gentle, considerate of the ongoing and immediate nature of irritability and can be used safely when disc herniation may be present. In some cases , as I proceed, it becomes clear that local and referred pain is increased with a particular segment ( had a case like this just this morning ), in which case it is appropriate to be as gentle as the situation demands. Persistance however, with gentle mobs , invaraibly settles things , such that a positive , less painfull , more mobile result is possible, within twenty minutes. In my own experience positive changes with respect to both irritation, referred pain and local tenderness is the norm, very rare for remarkable benefit to not happen. Just a reminder, the CM method is a gentle , moment by moment conversation betweeen therapists thumb(s) and spinal joint, muscle and soft tissues and their protective behaviours. It is not brutal, ultra powerful or risky . Skillfully applied there is nothing else that comes near it , as far as my own obs and readings can discover. As the central theme for intervention in cases where disc pathology is part of patients history ( ie more than three months previously ) then more pressures can be exerted , with the likelihood of focal and referred irritation being much less and a return to a non protected, mobile ,pain free state more rapid.

[Baecker]

Thx Ginger for the answer.

I tried the CM method of course according to Patients feedback and with gentle pressure, but with disc herniation i often see following problem: I start at that Segment which is likely referring the pain and after a minute or so the patient says he/she feels more pain in the periphery. And I am as gentle as possible with patient feedback. Thats the point i will stop cause as far as I know that is not a really good sign.

So what I understand from your post that you still continue even if there is more pain in that segment while mobilizing. Thats always the point where I stop at that time. Very interesting.

One more question you stay up to 20 minutes at a Segment? WOW. Man my thumbs start to cry after 3 minutes. LOL

[ginger]

Baecker, I don't continue at any one joint for more than it takes for that joint to offer evidence of positive change to resistance and tenderness. It would be rare to mob one joint for more than four or five minutes , in most cases it is more like 2. You speak in terms of segments, I rather speak in terms of specific joints, I mobilise unilateraly most often ( about 95 % ), with an occasional central PA if indicated. There is no doubt that initially , there will be some thumb discomfort, some unfortunately may attempt the method and not persist long enough for thumbs to come to terms with this and cease their complaints. In most cases this will take about a month ( from watching my own students this seems about standard ), progressively thumbs seem to gather strength and a certain steady sensitivity that continues to grow for a long time.
persist Baecker, your hands are better than you may think.

[Diane]

Ginger, I still can't imagine how you think you are directly affecting a "joint" with your "method."

Pardon me for my incredulity, but I want you to tell me again how you can be so sure that it's a "facet joint" through which you claim to gain your apparently amazing results, and not through a dorsal ramus, which, even though you seem to erase it conceptually, is still always going to be between your amazingly sturdy thumb and the "joint" target you think you are affecting, reflexively enacting neurodynamic effects through the entire system.

If you accept the anatomical reality of this, why do you persist in talking "joint" as if that was actually what you were treating? Thank you for what I anticipate will be an effort on your part to lead me through this one more time.

See picture.

[bernard]

Diane,

We know since a long time that Ginger has fairy hands and painful thumbs but joints are far from our possible touch.

[lloyd]

we did actually discharge this guy awhile back. he had lost most of his fear of movement just had a dull background ache with very little in the way of sharp pains and increasingly less movemnt restrictions . howevr we reached the end of what he needed to do for himself.:thumbs_up
mostly we just used graded exposure to movement in conjuction with plenty of explain pain and untwisting his thought processes
thanks
lloyd

[ginger]

Spinal fact joint mobilisation is not rocket science , not difficult to do or learn , has potential benefits that outweigh the minor discomforts of newcomers thumbs many times over. It is a standard approach in Australia . Those who practice facet joint mobilisation using methods originally pioneered by Maitland in Adelaide, have enjoyed a means to restore normal spinal joint movement which is safe , teachable to anyone who is capable of using their hands and capable of remedying a range of joint related neuralalgias as well. The Maitland methods have been taught at undergrad level here in Australian Physiotherapy schools for over thirty years. I do remember during my 6 month working "holiday"in Britain , in the late eighties, that it was viewed as revolutionary amongst those trained in that country. I was forever being asked to teach it and demonstate its use. Seems other countries have a very different take , culture I should say , on many of the methods commonly used here.
What needs to be considered perhaps a priori, is that when attempting to convey the value of something over the wire, I can never offer a view that comes near to a demonstation. I have , many times attempted to convey an impression of a practical , safe alternative to those I read about here. Often , at least on this site , to a chorus of "prove it" or "thats impossible", I remember having similar comments made, prior to demonstation , during my working time in Britain .
Seems that when a person is oriented towards thinking in a particular way, it becomes near impossible to achieve a shift towards alternate views. I must guard against doing so myself.

When I mobilise, my thumbs are placed at the lateral mass of a vertebral segment , such that pressure when exerted, downwards , with a slight rotation due to my position at the side of the patient, is an attempt passively to reproduce what would be a combination of rotation , side flexion and extension of the joint nearest to my thumb.
As I do so , I am aware that the movement is resisted or not , depending on the state of affairs at that joint. In cases where pain is elicited with this attempt, then resistance is also felt to much the same degree . That is , the resistance to movement is matched by pain. Were I to move my pressure to a place not in contact with the lateral mass, this feedback does not occur. When I align my thumb such that a close match is created with known anatomical landmarks at or near the joint , resistance and pain can reliably be reproduced in cases where spinal pain had been reported . So , By doing so I have alerted both myself and the patient to a painfull dysfunctional locus that is invarably reported as "the' site of pain .
This proceedure is very well tolerated, even ejoyed.
Were I to stray from the immediate location of the lateral mass , and therefore the joint closest to it , the effect of these attempts at movement is lost. As I proceed with mobilisation , as a continuous passive movement ,with a rate of 2 per second, well within tolerance , but inducing pain , change takes place. The combination of resistance and pain alter , reducing over a period , in most cases of one to two minutes. It is not difficult for a trained pair of hands to notice resistance reductions , this occurrs at the same rate and time , in the same location as pain reduces. These changes are then seen , on follow up and active and other movement testing ,to provide a long term amelioration to the complained of spinal pain . By long term I mean , that a permament improvement can be achieved , by this treatment alone , in the state of freedom and comfort of the majority of spinal pain problems. This includes those situations that follow injury, chronic stiffness, and fatigue related conditions. This method has been the central platform for thousands of successfull treatments in my own career over 22 years. The trend I see repeated is that longer and longer pain free periods are achieved, till I am redundant , in those whose chronic spinal pain conditions had previously beem "treated' with exercise type intervention, modalities, manipulation, massage ,acupuncture etc etc.
While you may continue to have your own interpretations on the nature and physiology of these changes, what stands as a certainty, is that I and hundreds of others who use the CM and similar mobilisation treatments ,are able to repeat the induction of a restored spinal movement and comfort capacity, along with a reduction and elimination of somatic referred events , over and over again , across a broad range of presentations. This is everyday work for me, not difficult or unusual. The method is out here for all to consider , I charge nothing for my advice to you , nor for my willingness to guide you through it if you wish. Were you to be in melbourne , you would be welcome to attend one of any number of very low cost seminars I run . I have been teaching this method for many years . You may wish to continue to say it can't be so, or that couldn't work , but the CM method as described here, has been the mainstay of my own clinical problem solving for a very long time.
It could be that my interpretation of the physiology of these changes need further work, and that in the light of extensive research I may amend the proposed explanation . As it should be, till then I maintain that my written pieces on the physiology of spinal pain should be seen as an honest attempt to interpret what takes place, rather than a model for all things spinal/neurological / physiological. I've not come across a better model yet, including the ones I have read on this site.
All the best

[Diane]

Thank you Ginger.
I don't doubt that it works, I only dispute that you are pressing joints open when they are 1.5 to 2 inches in or that it's a joint mechanism at work when there is so much other sensitive body bits between thumb and presumed joint target. They are too deep. Nice perceptual fantasy though, nicely written.

[ginger]

"Perceptual fantasy", thats cool Di , now how could I incorporate that onto my business card? You're a gem.
I'm not opening joints with CM, not sure how that view could be supported. Rather, mobs simply offer a short range of physiological movement to joints otherwise held stll. The effective reductions in tone I have explained as a response to the flushing of synovium across the cartilage. It is this cartilage , living tissue ,that is denied the flushing effect of oxygen rich fluids while held still , as part of the ongoing tone increases of muscles intimate to the joint.
The decreases in tone are permanent, so long as there are no ongoing pathological or hyperirritability issues pertaining to the onset and maintenance of the local protective respopnse.
What I am doing is moving joints, much more specific than would be true for active movement, exercise etc. While a picture may give you the suggestion that these structures are hard to reach , the truth is they are not at all . Not even with a few cms of adipose added.

[Randy Dixon]

Diane,

If you can't affect the joints why is it so easy to get an audible pop when doing this, even if that is not the goal? While you can't separate the dermal influence when pressing this way, there is no evidence that there is any dermal influence, and the inseparable nature makes the inverse true, that you can't rule out joint influences.

[ginger]

Randy, you don't get an audible pop when doing this . You have confused this method with manipulation, quite different.

[nari]

Sproinger,

With your CMs, surely you get an audible pop or two? That's not via a manipulative thrust.
I would suspect that if anyone gets a pop while elongating an area of skin and immediate subcutaneous structures, he/she is being a bit heavy handed...

Nari

[ginger]

Nari, sorry no pops.

[Diane]

Pediculative sproinger,
If I read you right, you believe that to get any kind of change in muscle tone you have reach down, w-a-y-y-y-y down, through all those layers of skin/fat/muscle and fascia, get the joint to move, the magic joint, the synovium of which then feeds the cartilage, which then tells the muscle to soften and lengthen. I see.

Interesting. Very roundabout reflexivity with much mental machination.

What if I told you I can do that just by stretching skin?
(There are even pops sometimes, Nari, once in a blue moon - I expect they are reflexive too.)

[ginger]

Dianne, the lateral masses are quite easy to palpate, fall readily with small amounts of pressure to my thumbs and require little effort to move. There is no reaching way down as you describe, just reach out and , bingo, there it is . I'm quite happy for you to continue to stretch skin and extend where you are able to , the virtues of that method. I've not been able to , in my various attempts at skin stretching, reproduce the kind of very quick changes I can do with CM.
The interest I have in CM is a practical one .
By alerting myself to the likelihood of there being a referred pain event, CM is by far the most effective tool I have , for proving ,( by removing it)that a distal structure had a centrally mediated neural problem , rather than a local one.
There is no need having done that to consider any element of the nerve along its route to the complained of structure. No flossing , no rubbing . What I do find necessary sometimes is to restore normal length to dura. The results happily , are very long term. With complete resolution and a return to normal within a short treatment time frame ( one to three Rx). I'm happy to be able to discuss these issues with you here, because it has become clearer to me that we ( and many at SS ) are pretty much on the same page . Differences in our methods don't cause me concern, the willingness to regard each others work as valuable and worth a mature discussion is what I look for here.

[nari]

Ginger,

How about the really obese person with a back like a high density foam mattress? Or, as I found, a long time ago, the extremely muscular guy whose back is riddled with hypertrophic paraspinals?? What do you do there?

(Waaay back I offered to treat the aching thoracic spine of a colleague who was in an Olympic preselection water polo team. Yikes. A rhino might have been easier)

Just curious.

Nari

[ginger]

Nari there is essentially no hindrance to the CM method by either muscularity or obesity. I'm not massaging anything, just moving joints and related structures. Triathletes and elite swimmers have always been a part of my practice demographic , along with islander people from far north queensland who are really big.

[nari]

I am just curious as to how you 'reach' the ZPJ and its environs through such a dense 'barrier'.....

Nari

[Diane]

It seems for Ginger, the lateral masses of the vertebrae spring up to the surface for him. Nice.

[ginger]

Dianne , I have just the standard issue hands, my students invariably report a similar connection to lateral masses and related vertebral structures with no problem at all. These structures are really close to the surface , with the exception of L5S1, which is the only one that requires heavier pressures to connect well enough to provide feedback and movement. Are you treating humans? LoL.

[Luke Rickards]

What I am doing is moving joints, much more specific than would be true for active movementGinger,

If this is true, then one must suspect that any method of passive continous joint movement would give the same result.

an attempt passively to reproduce what would be a combination of rotation, side flexion and extensionSo, what if you were to, say, lay the patient on one side, the upper body rolled into rotation down to the culprit joint, the Lx placed in slight extension, and then using a contact on the ilium rock the pelvis gently to produce localised SB and rot to the identified segment. This would fit all the requirments of your theory but would not emmulate LES/multifidus massage, skin stretching, or any direct effect on the dorsal rami (not to mention the decreased load on one's thumbs). Perhaps when you do the study you should include a group that is treated in such a fashion so that you can better rule out the effcts of touching these local tissues directly.

What do you think?

[ginger]

Luke, are you busy for a month or so?, I need minds like yours. Your suggestion is elegant . I do struggle with the persistant guilty feeling that I'm not doing enough to engage the scientific process and wrassle it to the ground and tie its bandy legs. Are you in melbourne any time soon?

[Diane]

These structures are really close to the surface , with the exception of L5S1, which is the only one that requires heavier pressures to connect well enough to provide feedback and movement. Are you treating humans? LoL. Yes, humans only. I think your idea of what you think you are affecting would be easier felt on a greyhound; so I guess I should ask you if you are treating humans. (?) :)

I've looked hard at all this.. Lots of people, especially males, have L5/S1s buried behind not only masses of muscle but also ilia (http://www.somasimple.com/forums/attachment.php?attachmentid=1973&d=1171769293). This image shows only bone and nerves - other layers are able to be added through the magic of imaging to get out to the skin layer, but you can get an idea how thick the body wall is and how deep L5S1 is, relative to the posterior flare of the ilium.

Luke, your idea would go quite a way toward deconstructing the hypothesis Ginger holds dear, but which he says he would detach from/amend: ..in the light of extensive research I may amend the proposed explanation.

I submit that some contemplation of the actual anatomy would prepare the way. A good atlas of dissections of the back would be an easy place to start.

[ginger]

You are the first physio who has ever expressed any difficulty finding lateral masses Di, the first I have ever come across who has trouble with finding the bony landmarks that first year students are examined on after their first prac on spinal suface anatomy tutorials. Not sure how I can help bridge this gulf for you, perhaps we can just move on to physiology and leave the gaps as they are for now. I enjoy the meaningful displays of thoughtfullness you are capable of in these areas. Science begs us to be good observers, the messages I put forward here are that , my observations . In the quiet moments I get to reflect on those observations I assume no sense of completion. I may pause to gather more data, the minor disagreements I enjoy here are very useful for that purpose. It does seem that we are in near agreement on the nature of the central nervous system . That to ignore its integration into soma is to miss the most likely and valuable of resources and mechanisms for change. I support the notion that the joints are merely a place where muscle bone and neurons meet for a purpose, that physiologically they are powerful in the sensory map. That effects taking place there are able to be observed as part of a feedback loop that is modulated , sensed and initiated by nervous means. My contentions about joint behaviour are based on many years of observing them, their responses, their various limits, freedoms and painfull episodes. I offer my sense of this to the forum , not to be dismissed as a one size fits all joint jockey, that has been offered, for my brief amusement. Where we may speed along the road to better understanding , is to speak with reference to each others discoveries with respect and understanding . Should I stray from this stated intention , I beg you to pull me up and allow no more. I shall expect the same integrity and forebearance as I am willing to give . lets begin to see each others work as an honest and forthright contribution from peers, rather than the prattlings of distant protagonists.
I am truly sorry you have had no success in palpating the lateral masses I find so easily , I have no useful explanation for this Di , have another look, maybe be prepared to use a deeper firmer thumb pressure. start with the cervical spine, easiest of all.
Best of luck

[Diane]

Ginger, I do not dispute that they are there, only that there is much between my thumb and them. Yes, I used to think I was on them - I no longer do. I used to think I had to press them - I no longer do. I used to think I had to treat them - I no longer do. That is all.
About C spines, check out this (http://www.somasimple.com/forums/showpost.php?p=33193&postcount=3).

[luca m]

"Pardon me for my incredulity, but I want you to tell me again how you can be so sure that it's a "facet joint" through which you claim to gain your apparently amazing results, and not through a dorsal ramus"

and

This would fit all the requirments of your theory but would not emmulate LES/multifidus massage, skin stretching, or any direct effect on the dorsal rami

Correct me if I'm wrong but are facet joints not innervated by the medial branch of the dorsal ramus? My recollection is that two branches innervate each joint. The level above and below the joint each contribute to the innervation.

Could this not be the mechanism by which ginger's CM work?

[lloyd]

hmmm, what to say? I'm maitland trained - Gwen Jull was my tutor at Queensland uni so I dont have any trouble locating lateral masses or that joints likely move with pressure and find CM a very useful technique. I remember reading Grieve aways back and his personal observation that he felt the effects were neurological rather than mechanical. I always remember it because it was a pretty radical statement given the climate of the day. I cant find where it was though i've looked. This opinion has been backed the more i've read recently not least on this site. Fluid lubricating facet joints doesnt work for me as an explanation of the cause of benifit ,there is simply too much going on ,on too many different levels. Two nervous systems interacting.
My bet is that Ginger gets such good results becuse he does his work so sensitivly much in the way of the fellow in dianne's last post- which was great and certainly inspires me deepen the listening in my hands and body.And possibly he has the walking placebo nature.
But i also reckon that If CM's were such an allencompassing technique as you seem to be suggesting Ginger ,David Butler and Louis Gifford ( who worked in maitlands practice ) whould not have had the call to go off on the productive routes they've taken.
I certainly didnt feel like facet joint mobs was the way to go with the fellow that this thread initially started about .Maybe now once his system has unwound it could have been encorporated with benifit but its by the by now as he's no longer in treatment

and this all started up again cause someone fell inlove with my kids.
funny old world.
regards
lloyd:love:

[nari]

Hi Lloyd

I too was a Qld Uni graduate, but Gwen was still in secondary school way back then. Mobilisations had not been invented.

I think that Maitland figured that stiffness = pain and therefore movement was the key to pain resolution; that is quite valid today, but the stiffness= pain bit was proved erroneous. I understand that he acknowledged Butler and Gifford's neurodynamic work as a way of explaining why passive mobs are effective.
I could feel ZPJs in most of the spine, but was never convinced that sproinging over the joint actually was the premise for pain resolution. Not when I later did very superficial work along the paraspinals with the same effect. What really leaped out at me was the simple fact that light cephalad pressure over the thoraco-lumbar junction did wonders with the technique of PKB and cranky femoral nerves. The knee bend restriction just melted away in a couple of seconds, increasing knee flexion by 20-30 degrees or so and pain disappearing. That was without any attention to submerged ZPJs....:)

As for your fellow who started this thread, it sounds like you guided him into graded activity and reduced the threat factor. Importantly, he basically improved due to his own motivation, with assurance from you. Great stuff.

Nari

[Diane]

Hi luca m,
"Pardon me for my incredulity, but I want you to tell me again how you can be so sure that it's a "facet joint" through which you claim to gain your apparently amazing results, and not through a dorsal ramus"

and

Quote:
This would fit all the requirments of your theory but would not emmulate LES/multifidus massage, skin stretching, or any direct effect on the dorsal rami
Correct me if I'm wrong but are facet joints not innervated by the medial branch of the dorsal ramus? My recollection is that two branches innervate each joint. The level above and below the joint each contribute to the innervation.

Could this not be the mechanism by which ginger's CM work?

Maybe, but I expect if it does it's reflexive rather than directly, mechanically as a result of Ginger's tender ministrations.
The dorsal cutaneous nerve would pick up the first contact from the environment (i.e., Ginger) and report straight to the brain while other bits of the nervous system more locally got busy simultaneously with their autonomic motor output, etc., maybe even lubing that joint. Maybe.

The muscles of the spine are all reflexive as well, pulling against each other to permit spinal movement smoothly, unless there's a glitch in the nervous system to inhibit them. At least that's how I understand them. What's tragic to me is that those little dorsal rami have to work their way up through all that stuff to get to the surface. I'm sure that "notalgia paresthetica" or dorsal ramus tunnel syndrome is a lot more common than we would be led to believe.

[ginger]

Lloyd , your kids are gorgeous by the way, anyhow , re your comment about Butler and Gifford not picking up on the thread of CM , probably because they hadn't known about it. It is my own work over the last twenty years that has lead me to use the term Continuous Mobilisation to describe a method that is not the same as Maitland's , or as far as I can tell any other method.
Apart from my own students , the only other means I have used to broadcast details of CM has been on this site and Rehab Edge , over the last 24 months. The term CM has crept into my descriptions over the last 6 months.
I would love to have the opportunity to discuss CM and my theoretical view of the physiology of spinal interaction with pain and behavioural change. That would be sensational. Maybe it will happen.
It is possible to get plenty of encouragements here amongst the well meaning jibes, hope you stick around.
Cheers

[Luke Rickards]

Thanks for the offer Ginger, but I'm very preoccupied with my own research and packing up here to move to France in Sept - no plans to come to Melbourne between now and then. Any osteopath in your area can show you how to perform the technique mentioned.

[luca m]

Hi Diane,

I agree that it is less likely a mechanical reason for the results that ginger sees with his mob. technique. And I agree that a dorsal cutaneous nerve will have a supraspinal transmission. I'm not sure what you mean when you say that joints and muscles work reflexively. I am interpreting that as a spinal reflex with little or no supraspinal transmission.

If dorsal structures (joints, muscles, fascia, skin) are almost all innervated by dorsal ramus nerves then would they not all reach the brain in the same way, as well as all have a reflex arc at the spinal level?

Again I agree that the cutaneous nerve network is very dense and is the first contact made, and probably stimulates the brain to a greater magnitude. I also agree that a deeper contact/pressure (say attempting to move joint capsules) can often be perceived by the system as a threat and have negative results.

But if the system did not perceive deeper contact as a threat then wouldn't the magnitude of stimulation to the brain from all dorsal ramus fibres, at all depths be that much greater and that much more beneficial? And maybe, with the continuous movement ginger uses, he is teaching the brain that what initially was perceived as a threat may not be so bad after all?

Just hypothesizing!

P.S. lloyd, your kids are terribly cute. Maybe even as cute as my 3 boys!

[Diane]

I'm sure your explanation is much closer to what actually happens luca m. :)

Like I said before, I don't dispute and I don't think anyone disputes that the "thumbs-into-the-back" thing "works".. everything "works"... The point is, how?, and your hypothesis comes closer to reality than does Ginger's, acknowleges and accounts for more of the "stuff" that exists between thumbs and facet joints, especially the signalling structures of nerve.

[Jon Newman]

But if the system did not perceive deeper contact as a threat then wouldn't the magnitude of stimulation to the brain from all dorsal ramus fibres, at all depths be that much greater and that much more beneficial?

Perhaps not. Consider this

http://www.barrettdorko.com/articles/rivers.htm

and

Weber Fechner (http://en.wikipedia.org/wiki/Weber%E2%80%93Fechner_law)

[lloyd]

I agree with Luca. I regularly use quite deepish pressure into tissues that are uncomfortable.As Gifford has said the question' is that a good pain' is useful. Pain itself is an interpretation by the nervous system and its threat value a further evaluation. Each individuals person history will be inportant as is the context.

People in general are out of touch with their pains and bodies.they have often been ignoring both for a long time. For some, deep even painful touch into an area that has been problematic can be paradoxically a great relief. Finally there is attention there.If The context is well set , communication and trust are is place. People can process the sympathetic charge quite well. If they can remain engaged and relaxed their tissues and nervous system can let go. Its a form of graded exposure, what peter levine called titration.

pesonally if i'm getting a massage i like it deep , as long as its sensitive.
maybe its because i'm a male ,wrestling ,rugby playing type- but i like to feel in that firm contact sort of way.it helps me feel my body.Light stroking is also delightful -in the right context.

Luca i would need photographic evidence to believe that your boys could possibly be more beautiful than mine.

:love:
lloyd

[Baecker]

Hi Lloyd


I could feel ZPJs in most of the spine, but was never convinced that sproinging over the joint actually was the premise for pain resolution. Not when I later did very superficial work along the paraspinals with the same effect. What really leaped out at me was the simple fact that light cephalad pressure over the thoraco-lumbar junction did wonders with the technique of PKB and cranky femoral nerves. The knee bend restriction just melted away in a couple of seconds, increasing knee flexion by 20-30 degrees or so and pain disappearing. That was without any attention to submerged ZPJs....:)

Nari

Would you mind to explain your TL Junction method a little bit more in detail?

Lots of LBP patients I think have problems in that area.

[nari]

Baeker,

I haven't done this technique for some years as my clientele changed to just persistent pain people.
While doing a PKB to feel the resistance of the movement and reproduce the pain (incidentally) I serendipitously laid a hand over the TLJ and as a result, stretched the skin a bit in a cephalad direction.
With slighly more pressure the patient reported: That feels good. All resistance to the prone knee flexion disappeared along with the reproduced pain.
At the time I had no idea what was happening; the pressure was never heavy enough to alter the pelvic tilt or anything like that.
The only explanation which came to light recently was the skin stretch, but I didn't know about that at the time. On standing, the patient's pain had decreased to discomfort only. Like most musculoskeletal work, it did not resolve the pain forever, but function did improve significantly.
Colleagues took it for granted that the pelvic tilt had changed, but I know that did not happen.

Nari