Ask almost any physiotherapist and they will tell you that one of the great things about our career is that you literally can learn something new every day. This is important because staying up to date on current research helps to provide the best care possible for our patients. I have only had my PT license for approximately one month, but I have already learned 3 things that change the way I assess/treat patients compared to what was taught in school and on the boards.
#1 – Arthrokinematics are important, but probably not as important as we think.
Arthrokinematics is a topic that I have written extensively about in the past. See link and post for more details. https://lukedelorenzo.wordpress.com/2011/07/27/arthrokinematics-an-important-biomechanical-concept/. Arthrokinematics is a biomechanical concept that explains joint motion during physiological movement of bones (osteokinematics). Understanding each and every joint arthrokinematic movement was said to be very important in the direction of joint mobilization interventions. This is why we had to memorize them in school and to pass the boards. However, as I more recently discovered, they may not be as important as we thought. I am not saying by any stretch that I wasted my time. As a matter of fact, memorizing each one probably helped me to become a better clinician and I would be lying if I said that I have abandoned this concept all together. But, I can say that it is much less important to me.
Not sure that this quite covers it…
There are two main methodologies that have brought me to this new conclusion. They are the Maitland and McKenzie Approaches. The Maitland Approach bases most of their evaluation process on a “comparable sign,” and McKenzie talks extensively about repeated motions and a direction preference. While they are dissimilar in some ways they both agree upon the importance of the subjective and objective portions of the evaluation, and having a baseline to measure outcome effects. Maitland’s baseline is the “comparable sign” which is simply the reason or symptom for the patient being in the clinic. For example, if a patient perceives pain when he rotates his trunk to the left this is your “comparable sign.” You simply perform some type of intervention and then retest the “comparable sign.” If the patient has improved, continue or progress the intervention. Simple. The other thing that Maitland is teaching is that you do not have to perform the intervention based on biomechanical principles. Without going into too much detail, research is allowing us to understand that most treatments work because of some type of neurophysiological effect. This does not mean that biomechanics or arthrokinematics or tissue extensibility is not improved, it just means that something happened and we can really be sure what it was. McKenzie attempts to place a patient in a category based on a systematic evaluation process. Once sub-grouped, a movement preference is established and repeated movements are commenced. Once the movements are performed, the baseline is re-tested to measure effectiveness. An example of this is how a patient with a limitation into DF may be given repeated end range PF. As long as the patient was sub-grouped into the correct category, outcomes are usually good. And, needless to say, it does not directly follow biomechanics principle. Another example is thrust joint manipulation. Recent research suggests that specific thrust techniques result in a similar outcome to general manipulations.
The McKenzie Approach is a lot more than just this…
#2 – Screening the joint above and the joint below probably is not enough
The second point is based on a concept called “Regional Interdependence” (RI). A concept that was covered in school and on the boards. RI means that an area of the body distant to the area of interest can be causing the dysfunction or symptoms. In other words, your knee pain may not be from a structure in your knee. In school, we are taught about RI for situations such as neck dysfunction causing shoulder, elbow, or hand pain, and low back dysfunction causing hip, knee, or foot pain. But, there may be more to it. Recently, I attended the level 1 SFMA course which goes into great detail about regional interdependence and the importance of assessment movement patterns. For anyone interested in my opinion, the SFMA was awesome, but to use the breakouts in their entirety in the amount of time usually given for an eval (45-60 minutes) will take some practice. Anyways, if we are going to truly embrace the RI concept we have to look at the whole person. If someone has knee pain we should understand that screening the hip and the ankle is incomplete especially if we do it passively.
Standard operating procedure? It just might be.
____________#3 – Pain is an output__________________
Pain research is a very popular topic these days. With principles such as “the neuromatrix” and “the biopychosocial model” we are fairly certain that pain is multifaceted and that basic pain teaching that begins and ends with nociception is incomplete. I will be the first to admit that I have only touched the tip of the iceberg when it comes to understanding this concept, but the common suggestion is that the amount of pain felt (or more appropriately, perceived) is not always proportionate to the extent of tissue damage. A great example was given in a video lecture that I saw from Dr. Lorimer Moseley, a physio and researcher who has helped bring these concepts to light. In his lecture, Dr. Moseley discusses how he was walking in the woods and felt a pinch on his leg. He assumed it was a stick, did not feel pain and did not think anything of it. He continues to explain that the next thing he remembered was waking up in the hospital two days later! The small pinch from the stick was actually a poisonous snake. A few years later he was walking in the same woods, and felt a pinch in similar portion of his leg. Immediately he was screaming and rolling on the ground in excruciating pain. This time, it was a stick. His point is that his previous experience increased his perceived threat and his brain created a larger pain output response.