REP 1: IN TREATING OUR PATIENTS, ARE WE ALWAYS PUTTING THE EMPHASIS IN THE RIGHT PLACE?
As I sit here beginning to write this article, my heart beats harder and faster, and I start to feel a little nauseous with the slight feeling of discomfort developing in my left arm. My left arm gets more sore and I start messing up my e’s and t’s…oh no!!! How am I going to write this article with this left arm problem? What could be wrong with my arm?
The Big Idea
Are we getting to the heart of our diagnosis and treating of the problem, or are we simply relieving the symptoms based on the complaints of our clients/patients? This is a dilemma that I face every day at work: what is the cause of the problem and how do all these regional factors influence it? And, in sport and preventative medicine, when we see these problems in the absence of symptoms, should we intervene and start corrective exercises aimed at minimizing these faulty patterns prior to the onset of musculoskeletal pain symptoms?
My take on things
I am going to use a variety of articles and videos to create some thinking!
So, what do you do for a living?
A while back, I read an article in JOSPT called Associations Between Turnout And Lower Extremity Injuries In Classical Ballet Dancers. It was the first that I have come across that demonstrated the need for physical therapists to evaluate how people move, just as much as we look at our classic tests of active and passive range of motion. It would seem from this article that functional measures of turnout are more relevant than hip external range of motion to prevalence of non-traumatic dance injuries.
If you want to get a good perspective of ballet’s need for stability/alignment/movement/strength/balance, while keeping the beat (and of course looking good) check out:
BOSU Balance Exercise – Ballet by Barry Drummond(English National Ballet)
But it doesn’t hurt over there
More recently, a narrative review titled A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications reminded us that “a patient’s primary musculoskeletal symptom(s) may be directly or indirectly related to or influenced by impairments from various body symptoms regardless of proximity to the primary symptom(s)”. The article also offered a nice illustrationof this interdependence of the musculoskeletal, somatovisceral, biopsychosocial, neurophysiological, and the need for adaptive allostasis processes to keep our bodies in homeostasis and injury free. As physical therapists, we must be able to evaluate not only the “regional area of symptoms” that our clients/patients present with, but look beyond the boundaries of our conventional training. To look not only at other musculoskeletal regions, but all of the other regions presented in this model and identify what is causing or influencing the complaint symptoms. To work well, this type of assessment requires a very connected inter-disciplinary team, all approaching the diagnosis from a regional interdependence model perspective.
Are patients over-training or under-recovering?
This leads me to question: do we really have an injury problem or a management problem for most of our non-traumatic musculoskeletal injuries? Maybe the problems are not over-use like we are prone to think, but rather problems of under-recovery. Maybe we’re not allowing our systems to adapt and regain a state of homeostasis. This, too, would fit the regional interdependence model.
As physical therapists, we must consider the influence of training loads, nutrition, sleep, and psychosocial factors on our clients’/patients’ recovery from non-traumatic musculoskeletal injuries. Check out TeamUSA.org’s Olympic Coach Magazine – this entire issue is on recovery!
Now back to the task at hand…my left arm pain!
So in treating my left arm, as physical therapists, are we simply going to evaluate and treat all of the musculoskeletal dysfunctions that would be found in this 50 year old arm, or should we dig deeper to the heart of the problem?
A recent article in the British Journal of Sport Medicine titled Specific exercise effects of preventive neuromuscular training intervention on anterior cruciate ligament injury risk reduction in young females: meta-analysis and subgroup analysis (unfortunately, not open-access), suggested that “strengthening, proximal control exercises and multi-exercise genres increase the efficacy of preventative neuromuscular training intervention designed to reduce ACL injury in young female athletes”. The thing that I took from this article was really PT 101:
- there is always a need for strength – weak never wins!
- don’t be rude, think of Rood; proximal stability with distal movement = skill
- think of nature; diversity is the key to stability
The interesting thing is that the researchers found that plyometric exercises have a positive indicator that was non-significant as part of the preventative neuromuscular training, while balance training demonstrated no influence as part of the preventative program. The authors went on to explain that the balance programming implemented within the programs may have not provided adequate training response based on the exercise selection and dose response.
Hey, kind of like my arm pain!
I took some extra strength acetaminophen with little influence on my arm pain. I thought the acetaminophen would get to the heart of my arm pain? Guess not…wrong drug, wrong dose… My life must be out of balance!
Another problem that I see in our world when honing in on the root cause: basic exercise physiology and training program development. When we make our “Exercise is Medicine” prescription, are we being accurate enough with our prescription and targeting the causative factors associated with the problem? Gone are the days that 3 x 10 reps of squats is good enough as our go-to prescription!
OK, enough rambling, let’s get back to my dilemma and my “Big Idea”.
I think we as physical therapists need to take an in-depth look at how we assess and evaluate our clients/patients when they present with non-traumatic musculoskeletal pain symptoms. We must consider the following:
- How they move:
- Assessing and evaluating the joints and muscles around the areas of complaint, but also within the regional kinematic chain that is a component of the skill that is causative in creating the onset of the symptoms. (Look at the position of the arms in the ballet dancer again and how they influence the movement. Should we not be looking at those when talking about the hip/knee/ankle?)
- Where and how they get stability to initiate distal movement, and whether the movement changes stability development and magnitude
- Alignment, and how their movement influences it
- What are all the factors that are not musculoskeletal in nature that could be causative to the complaint?It is here that we must have our interdisciplinary team ready to assist in solving the regional interdependence causing the complaints. So, as physical therapists we must be comfortable in asking questions about medical history, training patterns, sleep, nutrition, psychosocial status in attempt to direct to the appropriate health care professional.
- Focus on the fundamentals of treatment: think physics and anatomy is what I say! Remember they are Newton’s Laws, not Newton’s Ideas.
- Movement First – must have pain-free active range of motion
- Stability Second – You can’t create force unless you have equal and opposite stability.
- Strength Third – F=ma! Remember, we need to get things moving, and stop them from moving
- Fitness Always – Always develop an appropriate exercise physiology fitness plan that addresses the energy system requirements for your client/patient
- Problem Later? – If we know it is going to be a problem later, fix it now! That is where we should be going as a profession – real preventative musculoskeletal health management for injury prevention and performance.
Hey, my arm pain! Could my heart be the cause?
For years we have all spent time talking about the need for preventative care for cardiovascular health and early recognition of the signs and symptoms for heart disease. Why is it that we can’t think of our musculoskeletal system in the same way?
Well, it is almost lunch and I must get in my cardiovascular training with a 30 minute steady state run…. But is this what I really need? Or, should I really have had better sitting posture (…where is my standing desk?), used a keyboard and mouse and not my laptop, got more sleep last night, eaten breakfast, spent time with my friends and family, etc., etc., etc…?
We do not live in a simple world with simple problems. As I quote often: “If winning was easy, everyone would do it”! A challenge in our profession is finding the root of the problem and effectively treating it with a well-integrated multi-disciplinary team – not easy! Another challenge is getting back to our roots and remembering that we are movement and exercise experts, with the goal of keeping our patients/clients moving at the highest level of function available to them.
In case you’re interested in exploring any of these ideas more in depth, here are the full citations for the main papers we talked about above:
Sueki, Derrick G., Joshua A. Cleland, and Robert S. Wainner. “A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications.” Journal of Manual & Manipulative Therapy 21.2 (2013): 90-102.
Negus, Vicki, Diana Hopper, and N. Kathryn Briffa. “Associations between turnout and lower extremity injuries in classical ballet dancers.” Journal of Orthopaedic & Sports Physical Therapy35.5 (2005): 307-318.
Sugimoto, Dai, Myer, Gregory D., Barber Foss, Kim D., and Hewett, Timothy E. “Specific exercise effects of preventive neuromuscular training intervention on anterior cruciate ligament injury risk reduction in young females: meta-analysis and subgroup analysis.” British Journal of Sports Medicine (2014): bjsports-2014.
Do you deal with musculoskeletal problems that aren’t always what they seem? Have some fundamental exercise prescription beliefs that you’d like to share?
Chime in using the comments box below, or via the CPA Facebook page or on Twitter (hashtag #CPA30Reps).
About Bruce Craven
Bruce is the sport therapies discipline lead for Own the Podium’s National Sport Science and Medicine Advisory Committee, and the Integrated Support Team lead for the Canadian Paralympic Committee for the Canadian Sport Center Saskatchewan. Bruce is an Associate Clinical Professor in the School of Physical Therapy, and a Sessional Lecturer in the College of Kinesiology, both at the University of Saskatchewan. He also consults in the areas of Exercise Physiology, Strength and Conditioning, Performance Analysis and Sport Physiotherapy for the Sport Medicine and Science Council of Saskatchewan and the Canadian Sport Center Saskatchewan.
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