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Do Biomechanics Matter?

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  • #76
    Frustrated, I wrote this short piece for my website about core stability/strength/weakness etc. It's pitched at patients and is an attempt to help them take a first step away from conventional/popular core stability ideas. Perhaps you can use some of what I've written to help strike a balance between having to fit in with your colleagues while providing the patient a better narrative.

    http://coogeebay.physio/weak-core/

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    • #77
      Barrett mentioned this above.
      The Rational Clinical Exam for shoulder rotator cuff disease
      http://bit.ly/2dwjVae
      Jason Silvernail DPT, DSc, FAAOMPT
      Board-Certified in Orthopedic Physical Therapy
      Fellowship-Trained in Orthopedic Manual Therapy

      Certified Strength and Conditioning Specialist


      The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

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      • #78
        Thanks Jason. I think this makes things clear.

        Jumping to the surgery depends upon many things. The competence of the therapy available and challenges the patient plans on putting the anatomy through among them.

        Sometimes, plans change. Therapy seems to have changed too.
        Barrett L. Dorko

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        • #79
          To piggy back off Jason's post.

          The evaluation becomes: rule out red flags, basic physical exam, "do you think you'll get better here?"

          http://bjsm.bmj.com/content/early/20...16-096084.full

          Followed by a simple exercise...

          http://eprints.whiterose.ac.uk/87978/3/WRRO_87978.pdf

          Cut out the non-sense, keep it simple
          I may not be as smart as most people, but I'm sure as hell not as dumb....
          "The views expressed here are my own and do not reflect the views of my employer."

          Comment


          • #80
            A patient comes in with rounded shoulders, tight pecs, weak scapular retractors, positive neers/hawkins kennedy etc.

            Biomechanically the thought would be to stretch the pecs, strengthen the scapular retractors to "open up" the subacromial space to take load off of the tissue. It usually works but was it the preceding clinical judgement that which actually solved the pain issue? Or was it something else? Maybe it was natural history?
            Adding: And the pain goes away, and everyone is happy. But the subacromial space remains the same, which we conveniently ignore. So the whole point of doing the exercise in the first place is not affected. Think about it for a minute. The same goes disc herniations and scapular dysfunction.
            Anoop Balachandran
            EXERCISE BIOLOGY - The Science of Exercise & Nutrition

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            • #81
              Maybe things that explain how it is people "got better" aren't quite what they might be.

              What might be said about that has been said many times, and now we're seeing someone say, "If everything "works," what does it matter what is said?"

              Perhaps you can imagine what I think of that. I'm wondering what other therapists think.
              Barrett L. Dorko

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              • #82
                Originally posted by anoopbal View Post
                Adding: And the pain goes away, and everyone is happy. But the subacromial space remains the same, which we conveniently ignore. So the whole point of doing the exercise in the first place is not affected. Think about it for a minute. The same goes disc herniations and scapular dysfunction.
                Anoop,

                Your statement is why I've begun to view rehab in this fashion:

                If you're seeing me on the clock, I'll use a graded approach and education to you return back to activity. If you aren't seeing me in the clinic and just asking my advice off the clock. If the pain goes away, great. If it doesn't, at least you can still do what you want.

                The funny thing is: both scenarios I've described probably have the same outcome.
                I may not be as smart as most people, but I'm sure as hell not as dumb....
                "The views expressed here are my own and do not reflect the views of my employer."

                Comment


                • #83
                  Originally posted by Barrett Dorko View Post
                  Maybe things that explain how it is people "got better" aren't quite what they might be.

                  What might be said about that has been said many times, and now we're seeing someone say, "If everything "works," what does it matter what is said?"

                  Perhaps you can imagine what I think of that. I'm wondering what other therapists think.
                  Words matter...
                  I may not be as smart as most people, but I'm sure as hell not as dumb....
                  "The views expressed here are my own and do not reflect the views of my employer."

                  Comment


                  • #84
                    I'd say:

                    Pretty much you can get anything to "work" with careful attention to the patient...but what truly matters is what you say.

                    For me the difference between a good clinician and a bad one is not really what they do....but rather what they say.

                    It's that simple in my mind.

                    Comment


                    • #85
                      Originally posted by Jason Silvernail View Post
                      Barrett mentioned this above.
                      The Rational Clinical Exam for shoulder rotator cuff disease
                      http://bit.ly/2dwjVae
                      Ah yes I've seen that video. Very, very helpful.

                      But what about thoracic outlet syndrome? Are you saying it doesn't really exist and most of the time it's a rotator cuff pathology? Because none of those tests were positive on these patients. How does one "treat" thoracic outlet syndrome conservatively without attempting to "alter" the biomechanics? Are there truly no exercises or manual treatments that can help open up the thoracic outlet? Or is PT for thoracic outlet merely a theatrical application of reassurance, placebo effect and natural history?

                      Comment


                      • #86
                        Frustrated,

                        Please don't forget that the biomechanics of the nervous tissue is important in "shoulder pain." And that all pain is neurogenic but the effect of movement is unpredictable. The characteristics of correction should accompany movement and, if using ideomotion secondary to Simple Contact, it will follow Wall's observations.

                        There are four origins of pain and I've only made the case for how movement will affect one of them.
                        Barrett L. Dorko

                        Comment


                        • #87
                          Originally posted by proud View Post
                          I'd say:

                          Pretty much you can get anything to "work" with careful attention to the patient...but what truly matters is what you say.

                          For me the difference between a good clinician and a bad one is not really what they do....but rather what they say.

                          It's that simple in my mind.
                          And HOW they say it...
                          I may not be as smart as most people, but I'm sure as hell not as dumb....
                          "The views expressed here are my own and do not reflect the views of my employer."

                          Comment


                          • #88
                            Originally posted by FrustratedNewGrad View Post
                            I have questions regarding thoracic outlet syndrome.

                            For some reason I've gotten 3 in the past month. The last one today had a prescription from the MD for rotator cuff tendonitis. Did he actually look at or touch the patient?

                            How would you treat something like this. I mean it's definitely a biomechanical issue no? The compression of the the nervous and/or vascular tissue in the thoracic outlet is what causes the symptoms. Can we actually relieve the compression with exercises and manual therapy?

                            Of course my colleagues say you can and I took their recommendations just because I wouldn't know how to treat it as a "ectodermist" (?) would.
                            I'm curious as to how TOS was diagnosed in the first place? From the literature, it appears there is a lack of standardised diagnostic criteria and a paucity of evidence for most interventions (https://www.ncbi.nlm.nih.gov/pubmed/25427003). Another recent study suggests surgery seems to be beneficial in treating TOS (https://www.ncbi.nlm.nih.gov/pubmed/27666803).

                            If there is compression of neurovascular structures then I think Barrett's idea of eliciting correction via movement is a plausible option. Maybe some gentle hands-on to calm the NS down a bit first. I would explore isometrics, low-load and stretching movements starting at the neck and shoulder to ascertain tolerance and pain thresholds, then progress from there.

                            Comment


                            • #89
                              Latest on the core (from Strength and Conditioning for Endurance Running by Richard Blagrove):

                              "Core stability seemed to become popular around a decade or so ago and has become one of the most debated and misunderstood areas of the fitness industry. Many practitioners and athletes talk about 'the core' like a group of magical muscles, that if strengthened will alleviate all injuries and make you run faster! Such misconceptions can often do more harm than good, result in hours of wasted training time, and at worse, actually cause injury. Although a strong trunk is important to help prevent injury and optimize your performance, unless you have a history of lower back pain, it is no more important than any other area of your strength and conditioning.

                              The term 'trunk training' is preferred to 'core stability' in a strength and conditioning setting, mainly because 'core' suggests that a single deep muscle in the region should be targeted with exercises, and 'stability' refers to the rigidity of the spine. Both of these reflect a narrow view of the function of muscles in this region."

                              Comment


                              • #90
                                Originally posted by Jason Silvernail View Post
                                Barrett mentioned this above.
                                The Rational Clinical Exam for shoulder rotator cuff disease
                                http://bit.ly/2dwjVae
                                Originally posted by Ken Jakalski View Post
                                Latest on the core (from Strength and Conditioning for Endurance Running by Richard Blagrove):

                                "Core stability seemed to become popular around a decade or so ago and has become one of the most debated and misunderstood areas of the fitness industry. Many practitioners and athletes talk about 'the core' like a group of magical muscles, that if strengthened will alleviate all injuries and make you run faster! Such misconceptions can often do more harm than good, result in hours of wasted training time, and at worse, actually cause injury. Although a strong trunk is important to help prevent injury and optimize your performance, unless you have a history of lower back pain, it is no more important than any other area of your strength and conditioning.

                                The term 'trunk training' is preferred to 'core stability' in a strength and conditioning setting, mainly because 'core' suggests that a single deep muscle in the region should be targeted with exercises, and 'stability' refers to the rigidity of the spine. Both of these reflect a narrow view of the function of muscles in this region."
                                I thought core strengthening for low back pain has pretty much been debunked as no more effective than a general exercise program.

                                http://bmcmusculoskeletdisord.biomed...71-2474-15-416

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