Integrating core stability into functional movement has long been one of those un-talked about subjects where the assumption is that prerequisite loading in other non-functional positions is then transferred into a loaded environment.  The model used to explain this is the classic model of motor learning described by Posner & Fitt’s in the late 1960’s, which describes three stages of motor learning:

The Cognitive phase

The Associative phase

The Autonomous phase

This model repeatedly surfaces in the physiotherapy rehabilitation literature as an framework for the sequential loading working towards functional tasks.  It should be pointed out that there are several other theories of motor learning which do not necessary follow this paradigm, but it also serves a dual purpose in the clinical environment, as interventions at the early phases using this strategy tend to be low load and therefore minimal risk / reduced likelihood of provocation.

However, there is an equally strong argument for the massive sensory bombardment, which occurs from using functional positions as a way to stimulate specific muscle activity.  Historically, the difficulty in clinical practice is to ascertain whether the target muscle groups are actually being recruited as part of a global functional movement pattern.  This undoubtedly remains the significant clinical challenge.

Some of the recent trends in athletic training involve the use of functional exercise programs, which try to replicate functional demands.  If we look at the frequent reports of symptom provocation from patients, there are some very familiar aggravating factors, which I think we would all recognise.

Sweeping & Hoovering

Carrying shopping

Walking the dog

Accessing car boots

Working in overhead positions

Twisting or reaching

It is clear from evaluating these positions that there is a change in the relationship between the thorax, the pelvis and the intervening lumbar spine and therefore some degree of mobility must accompany the necessary “stability” to counteract loading.

Because segmental rotation in the lumbar spine is very limited (estimated at 2º – 3º in each direction per segment) it would appear biomechanically that the majority of rotation must occur from the thoracic spine and the hips.  It is tempting to speculate that any impaired mobility in these areas maybe a significant driver to rotational pressures through the lumbar spine causing tissue sensitivity.

If we look at control of the lumbar spine during function from that perspective, the role of the oblique musculature (both abdominal and spinal) could be considered as “anti-rotation” muscles whose role is to minimise the stresses distributed to the Lumbar segmental structures.  In that situation the limbs and torso become the external “drivers” forcing load on the core..

Using this model to replicate function there are two key principles of loading.

1)    Asymmetrical stance

2)   Altering the loading segment (driver).

In reality this means that evaluating trunk stability needs to be assessed in conjunction with asymmetric limb loading which is more akin to normal activities of daily living.

Clinically, this means using positions such as:

Asymmetrical squat

Stride stance

Lunge

Single leg stance

as variations in the start position and combining this with variations in the loading force (driver), either using arms, torso or legs.  The degree of difficulty, hence risk of injury, is related to the magnitude of load with arms being the lowest, legs being second and torso being highest.

Whilst visual observation is how most of us rely on accessing the quality of movement there is certainly a limit to what can be achieved.  The big clinical decision is whether we can use load or speed of motion as the next level of exploration/provocation to see if we can elicit a breakdown in control.  Obviously this needs to be weighed up against the vulnerability of the pathology.
So from a practical perspective it is quicker and easier to initiate functional rehabilitation strategies as the prime intervention for low back pain patients unless their level of irritation contra-indicates or they do not tolerate the level of loading associated with function. Patients in that category may then self-select for lower loading regimes as an intermediate stage.

The alternative, and one which has become pervasive in recent years, is to work through a multitude of phases which may not particularly challenge the patient in a way that is relative to function, although appear deficient from the perspective of musculoskeletal control and ideal movement patterns. The well known phrase “Paralysis from Analysis” springs to mind.

Enjoy the clinical challenge.

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | One comment | Add to del.icio.us
Post tags: core, core stability, low back pain, lunges, motor learning, movement impairment syndromes, physiotherapy, single leg stance, squats, transversus abdominis, trunk control

Feed enhanced by Better Feed from Ozh

I’ve just had the great pleasure of listening and speaking with legendary All-Black rugby captain Sean Fitzpatrick. See: www.balls2business.com for Sean Fitzpatrick’s story and valuable information.

The conference was for clinicians and the theme of Sean’s talk was how to transfer the lessons of successful sports teams into clinical practise. Being a huge rugby fan it was great to meet a living legend but I was also really impressed with the message (as well as the messenger) and found it inspiring.

It got me thinking about applications to Physiotherapy and below are some thoughts based in Sean’s presentation.

What makes a global brand? What sets it apart from all other brands? How can lessons be learned from the All Black brand and applied to your own business?

The role of branding applied to physiotherapy can be considered in terms of the public perception of what physiotherapy has to offer (ie What is it?) or more specifically how it relates to the individual organisation/hospital/practice in which we conduct our business. The public perception of physiotherapy is very much based on their own interpretation or second-hand information unless they have been in a position where they have had previous care administered to them or a relative. Therefore, there frequently isn’t a yardstick by which to measure the competence of a therapist other than looking for familiar clues of ..

Professionalism

Communication skills

Personal presentation

Effectiveness of treatment.

Essentially patients are looking for solutions to problems and generally are not concerned about the clinical challenges which clinicians wrestle with in order to deliver optimum care.

I must confess it has taken me far too long to realise that the technical aspects of the job are only part of the essential core skills required.

“When the All Blacks win, I’d much rather be the All Blacks captain, and when they lose, I’d much rather be the prime minister.” Jim Bolger, ex-Prime Minister of New Zealand. How do you lead the All Blacks? How do you lead?

Again there are multiple levels to apply the analogy of strong leadership in physiotherapy practise. Those in a leadership role must communicate their vision and ensure that staff entrusted with delivering care are comfortable with the vision and it is consistent with their principals. It goes without saying that leaders should lead by example to have any credibility.

On an individual basis if we think about the qualities employed by effective leaders they would include..

Seeking advice

Collaboration

Decisive decision making

Implementation

Evaluation

Feedback

all of these concepts are equally applicable for a patient care plan delivered by a sole practioner – as Sean Fitzpatrick says “be the best you can”

The basis of sporting excellence is all about identifying, maximising, and then utilising your strengths. Find out how this is achieved in a sporting context, and how to transfer this understanding into your business.

No one can have all the answers. Recognising our skill limitations and the possibilities of better treatment options from other care providers is sometimes a humbling experience for a therapist. However, leaving aside the associated personal challenge our fundamental objective is to do what is best of the patient. If often seems these lines get blurred in daily practice. “Do what’s best for the patient” is a mission statement to start every therapist’s day.

Developing and implementing a plan to win a World Cup brought with it lessons and insights that might prove highly useful to those responsible for business planning.

As the saying goes “failing to plan means planning to fail.” As therapists we must have a clear vision and process of how we intend to pursue treatment and its delivery to a patient. We must also have a clear plan of recognising when our strategies are not being effective and need to be altered. Far too often patient’s failing to respond is transferred into blaming the patient for non-compliance rather than therapist self scrutiny.

Things to consider are..

Poor planning

Poor treatment delivery

Failure to recognise the potential limitations of the pathology

Failure to match expectations with reality

Sometimes the business requirement is to take the direct line, tackle the issue full-on, head to head. What can we learn from crash ball rugby about when – and how – this tactic can work best?

There are undoubtedly situations where clinicians have to take a chance and take risks As long as these risks are not reckless but calculated they are not negligent. The outcome may not always be positive, but if you don’t try you will never know. Fear of failure leads therapists to avoiding clinical decision making. Telling a player to return to a club training session with advice to “take it easy” instead of testing functional tolerance in a controlled environment or defining the boundaries loading parameters is an example of this. Having a patient “breakdown” during rehabilitation is not a pleasant experience but engineering this breakdown to happen away from the clinical environment is simply looking the other way! We need to take responsibility.

In 1986 a young team including thirteen debutants travelled half way round the world, and beat the reigning 5 Nations champions. How was this achieved? Succession planning…

Planning for continuity of care is the most obvious example that springs to mind. No matter what detail is recorded in clinical notes a 1 minute conversation between therapists can be more effective than hours of reading. Establishing a bond is a critical part of delivering care and drawing on the experience of face to face contact time is invaluable.

For example

Knowing there is an important upcoming competition

Knowing there are concerns about serious pathology

Wondering if things will ever get better

Conflicting information from healthcare providers

This type of detail not usually recorded in clinical notes but vital to shape the patient – therapist relationship.

Would you rather watch a team play beautiful rugby and lose, or watch a team grind out a win? And (whichever answer you give) which one would you rather play for? Is your business about process, or outcome?

Simply put as therapists we can get pre-occupied with technical aspects and new technologies but we need to constantly remind / test and re-test our interventions to ensure our work with a patient is effective. I’m old enough to remember using short wave diathermy and heat lamps for hours without any tangible measure of benefit. We have to make our contact time count!

Unfortunately, there isn’t a ready-made recipe. But this module includes a set of thoughts and insights from one of the great team leaders of one of the great teams in sporting history. What are the dynamics that you have to consider in order to get a collection of individuals to perform as a team at the very highest level?

The team can be within a department / practise or the wider application to multidisciplinary healthcare teams. Having “outsource” options for surgery, pain management, rheumatology, psychology, pharmacology are all necessary components of musculoskeletal pain management. Having confidence in the clinician is absolutely critical to deliver effective care.

I’ve lost count of how many times a treatment plan has been sabotaged by…

Dismissive comments

Trivialisation of symptoms

Flippant remarks

Superficial examination

Disinterest

Abrasive language

We need to know the team members if we are to have confidence in them. We don’t have to like them – just respect their clinical judgment. Matching the personality to the patient and be very valuable in the right circumstances. For example, an abrupt neurosurgeon dealing with an acute surgical disc prolapsed is far more acceptable than in a chronic pain management situation. A holistic pain specialist is more appropriate than an invasive pain specialist for a patient who fears needles!

I’m sure we’ll come back to this post in future and drill deeper into the points raised.

Some powerful lessons that we need to integrate into our practise.Please share your comments and opinions.

Enjoy the clinical challenge

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | 2 comments | Add to del.icio.us
Post tags: chronic disease, clinical examination, detached, Exercise, failed intervention, hydrotherapy, low back pain, managing poor prognosis, pain questionnaires, Patient attitude towards collaboration between the care providers, Patient confidence in care providers, Patient expectations, peak performance, persistent ongoing symptoms, physiotherapy, Previous response to treatment, primary care, professionalism, prognosis, psychosocial flags, quality assurance, sean fitzpatrick, subjective questioning, targeted therapy, therapist credibility, Type of interventions prescribed

Feed enhanced by Better Feed from Ozh

As clinicians we have been bombarded with research outlining the important role of psychosocial issues in clinical outcomes.  I have often wondered why these models have been applied to low back pain and whiplash but don’t seem to feature on the radar of many other chronic conditions we  see routinely.  Maybe it’s a case of chronic conditions such as osteoarthritis, ankylosing spondylitis, degenerative joint disease etc having more defined pathology and are therefore being a more acceptable diagnosis to patients thereby deflecting them from further questioning or seeking more treatment.

Regardless there is a vast array of measurement tools available for quantifying

psychosocial components. These include:

McGill Pain Questionnaire

SF36 Health status Questionnaire

Oswestry LBP Disability Questionnaire

Fear / Avoidance Index

Pain Catastrophization Index

Visual Analog Sacale

to name a few.

Taken in conjunction with the now widely accepted concept of Flags;

Red

Yellow

Black

Blue

Orange

we have a huge battery of questionnaires and a framework which can be used to elucidate individual characteristics and tendencies.  I have spent several years enquiring about the merits of these scales in primary care and arguing that specific questions interspersed within a subjective examination yield more direct information than a “profile questionnaire” yielding information about individual tendencies. For example “when are you planning on returning to work?” will yield some specific answers ranging from “never” to “when you get me better” to “when they say their sorry” etc…. Such responses present the clinician with an opportunity to challenge beliefs, identify obstacles or alter a management plan. Several authors of these tools acknowledge the basis of this argument but cite the lack of “research validity” for the approach I’ve outlined. I’ll let you be the judge of that!!!

One of the big challenges in an acute presentation is whether to initiate these type of investigating tools as part of a routine assessment protocol or whether to try to identify high risk patients relatively early in the intervention and alter management strategies accordingly.  On the face of it this might seem like an obvious management plan but there are some very real practical limitations to implementing it.

Firstly – if every acute patient is going to be screened using psychosocial profiling from day one then there are large numbers of patients who are going to be asked a lot of questions which they may perceive as being highly irrelevant to their primary (musculoskeletal) problem and the reason they consulted Physiotherapy.

I think this is particularly significant in the Private Care Sector where we deal with patients who are unlikely tolerate some of the enquiring questions contained in the questionnaires and the  perception of the type of treatment to be administered .  Remember again we are talking about an acute setting here not a chronic pain management setting where the patient mindset is in a different place.

Secondly, the challenge if we wait for recognition signs of slow response to treatment or unpredictable features which emerge as part of one-to-one contacts, three or four sessions into care, is how do we change our management strategy and sell it to a patient in a credible way?  By “selling to the patient” I mean providing a credible explanation for their symptoms, which may be contradictory to what was initially stated, based on the physical findings alone on initial assessment.  This is a major major issue, which is never discussed in formal literature but as clinicians, one which we must find practical strategies to address if we are to be in a position to deliver care.

So the issue of therapist credibility surfaces in two respects: Firstly,in that the explanatory mechanism of a patient’s symptoms may need to change as the therapist gets more information from increased patient contact time and behavioural observation.

Secondly, how do we start to change our rating scale factors to shift the hypothesised mechanism of symptoms from being nociceptive to more predominantly psychosocial?  Of course as in all things in life this is never a clear cut classification as there will be degrees of pain mechanisms in all presentations which may alter and vary as time goes by – ie they are dynamic.

We have discussed pain mechanisms in previous posts. So how do we rise to this challenge of changing our clinical hypothesis to facilitate a different management strategy and delivering that message effectively to our patients in order to achieve compliance?  This again is another un-talked about subject.  The therapist can feel assured in the knowledge that they are following International best practise guidelines to deliver a message which appears entirely credible to the therapist but does not appear so to the patient.  This is a classic situation of “blame the patient” for not listening to the message.  The challenge for the clinician therefore is to recognise early signs, which require a change in the hypothesis of symptom mechanisms. It also means careful consideration of the type of clinical discussions which occur in the early phases of a patient /therapist interaction. (and I don’t mean being “wishey washy/vague” when reporting clinical findings – just systematic and analytical).

Below is a checklist of strategies which maybe helpful in the clinic.

1 Be familiar with the content of international guidelines on management of acute LBP.

2. Develop an opinion o these guidlines (ie agree, disagree or select elements)

3 Evaluate the type of patient you are dealing with (ie tense, easygoing, enquiring, intimidated, hopeless, unrealistic, naive, diligent, self directed, victim etc…)

4 On the basis of your evaluation above be selective about the type of words used to describe symptoms.(ie  pain v’s symptoms, problems v’s disabilities etc).

5. Avoid the pitfall of” information overload” in patients who won’t / can’t process this.

6. Avoid , at all costs, the pitfall of” information overload” in patients who will mal-process / distort the information presented.

7 Be guarded about contradicting professional opinions which are contrary to your own (even if you think they are off-the-wall”). Careful dissection of inappropriate advice needs supportive analysis, not dismissal, and is the difference between alienating a patient and keeping them on board to deliver care.

8.Identify predictable /familiar elements of pain patterns which responses can be mapped.

9. Identify clinical /subjective response characteristics which are improving from treatment – even if the overall patient perception is of “no change”.

10 Eliminate / reduce “Nociceptive” pain mechanisms ie clinical signs of pain, stiffness, muscle spasm, loss of movement before concluding an alternative symptom mechanism (psychosocial). Blaming all symptoms on stress, tension, strained relationships, smoking, excessive weight is a sure-fire way to lose credibility.

I think there are a few more points to add to this list but that should suffice for some mental marination.

Enjoy the clinical challenge.

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | One comment | Add to del.icio.us
Post tags: chronic disease, clinical examination, detached, Exercise, failed intervention, hydrotherapy, low back pain, managing poor prognosis, pain questionnaires, Patient attitude towards collaboration between the care providers, Patient confidence in care providers, Patient expectations, persistent ongoing symptoms, physiotherapy, Previous response to treatment, primary care, prognosis, psychosocial flags, subjective questioning, targeted therapy, therapist credibility, Type of interventions prescribed, whiplash

Feed enhanced by Better Feed from Ozh

The link between hamstring strains and poor core stability is frequently casually referred to in rehabilitation and strengthening conditioning literature.  In fact it appears that there is no injury these days that is not associated with impaired “core stability”!

Has it taken over from excessive pronation as the ubiquitous explanation for intrinsic overuse injuries?

However, rarely do we see discussed the postulated mechanisms between impaired trunk control and potential hamstring overload. Here we will consider these hypotheses, the clinical testing methods and rehabilitation strategies to address these functional control deficits.

Mechanism of hamstring overload in “core” instability.

The basic premise of impaired trunk controls involvement in hamstring overload is that compromised proximal trunk control (muscular control above the pelvis) leads to a compensatory overstrain of muscles more distant in the chain, in this case muscles attaching to the lower end of the pelvis.  The analogy of a triangle standing upside down is a useful visual concept to explain this phenomenon.  In this situation we have the hamstrings posteriorly and the quadriceps anteriorly acting with the knee as a point of fixation and trying to balance the pelvis in an antero-posterior direction, almost like reins horse riding.

Importantly the control requirement is not entirely in an antero-posterior direction i.e. a sagittal plane but is in fact all 3 planes of motion:

Sagittal Plane

Coronal Plane

Transverse Plane.

However, it is easier to consider in each individual plane and build up the elements.

Simultaneous Concentric & Eccentric Loading

So the concept of excessive hamstring activity in order to balance the pelvis “from below up” is complicated by the fact that the hamstring muscle group crosses two joints – namely the hip and knee and in many sporting situations there are  simultaneous but different movements occurring at the hip and knee.  This is thought to predispose the hamstrings to alternating patterns of concentric and eccentric activity which maybe required simultaneously depending on the position of the respective hip and knee.

Primary & Secondary Hip Muscle Function

The situation is further compounded by the frequent clinical observation of impaired hip joint extension function i.e. inhibition of the prime one joint hip extensors- gluteus maximus in particular.  Vladimir Yanda described this many decades ago as part of the “cross pelvic” syndrome and although this was reported in a context of tight hip flexors causing secondary gluteal inhibition, the clinical observation in my experience is just as frequent in patients without tight hip flexors – (as measured by Thomas test).

So What?….

So the practical implication of this scenario is an increased loading through the hamstrings by combining both a stability and a mobility challenge.  If we explore this further in terms of functional consequences for muscle recruitment this is often evident as a poor coordination of hip extension (as measured in Yanda’s prone hip extension test).  Here the prone patient is asked to extend the hip an inch off the supporting surface and the clinician observes for the pattern of motion.  First one is looking for the timing of contraction between glutes and hamstrings on the lifting leg with the hypothesis being that the gluteus maximus should initiate the hip extension pattern followed closely by the hamstrings.  In regards to the torso contribution, the proximal pelvis needs to be stabilised in order to allow the 15 to 25kgs of leg to be lifted.  In the presence of  hamstring substitution for gluteus max and compromised trunk control this leg extension is often accompanied by a hyper- lordosis of the lumbar spine and then associated anterior pelvic tilt.  This represents a shift in compensation above the pelvis where the movement of hip extension is enhanced by excessive contribution of lumbar lordosis and paraspinal muscle activation.  A critical point to bear in mind with this movement pattern is that lumbar lordosis associated with paraspinal hyperactivity has the complicating effect of relative inhibition of the anterior abdominal wall, which perpetuates the cycle of global core instability.

Clinical Solution

Previous posts outlined the sequence of progressions for proximal trunk control in this plane.  I don’t need to reiterate them here but follow the link provided for further explanation.  One of the most useful clinical exercises/tests is what I often refer to as tri- bike hip extension.  In this position the patient is in a crouched kneeling position (as a triathlon bike rider) with one leg trailing back behind.  The trailing knee is then bent and the test/exercise is to lift the leg by driving the heel towards the ceiling.  Most importantly – the lower the crouch position the greater the degree of difficulty on lift.

I find this an extremely potent test for evaluating hip extensor function and it also yields good information about trunk stability and compensatory strategies but more on that  another time.

P.S. When patients cramp in the hamstring, doing this exercise, you can bet your bottom dollar they are still trying to use the hamstring as opposed to gluteus maximus to execute this movement.  In that event one needs to revert to a less challenging position.

Enjoy the clinical challenge.

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | No comment | Add to del.icio.us
Post tags: Biceps femoris, clinical measurementm core stability, gray cook, Hamstring Flexibility deficits, hamstring rehabilitation, Hamstring strain, hamstring treatment, low back pain, movement patterns, multifidus, muscle tone, peter o'sullivan, saggittal plane mechanics, Semimembranosis, Semitendinosus, Shirley Sarhmann, strength testing, transversus abdominis

Feed enhanced by Better Feed from Ozh

Equally important is the identification of patterns of symptoms, which do not appear directly related to mechanical factors which are potentially intractable and unresponsive to physiotherapy.  The delicate balance to be struck here is whether to pursue legitimate treatments which have some realistic possibility of producing significant improvement, countered against the potential for giving the patient false hope with the consequent negative impact of yet another failed intervention.

What factors constitute significant improvement?

Now there’s a topic for another day!!

Factors determining information delivery:

Previous response to treatment

Type of interventions prescribed.

Patient expectations

Patient confidence in care providers

Patient attitude towards collaboration between the care providers (hostile, enthusiastic, detached, despondant)

Patient attitude to the level of disability associated with their condition.

At the other end of the spectrum are patients who present with  acute symptoms  in “high risk” areas – where know there is a strong propensity for chronicity (whiplash and acute low back pain). There is a delicate balance to be struck between trivialising modest physical findings and associating them with a short response time.  This of course fatally damages the therapist’s credibility if the symptoms have not resolved within the predicted short response time.  Alternatively, stating protracted recovery times or extended periods of disability may well become a self fulfilling prophecy.

In this situation the way to manage all acute presentations is to have structured milestones and goals in order to assess the rate of progress.  If this format is applied then patients who are responding at a slower rate can be recognised early and the therapist can equate the level of progression observed over time with the sequence of stages required to achieve full return to function.  This is not the same as telling a patient it may take a year to get better but they are unlikely to see improvement in a given specific functional deficit if they still have symptoms or discomfort when challenged at a lower level.  Therefore, equating functional tolerance with symptom characteristics is an important yardstick for both therapist and patient to monitor.

Enjoy the clinical challenge.
David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | One comment | Add to del.icio.us
Post tags: detached, Exercise, failed intervention, hydrotherapy, low back pain, managing poor prognosis, Patient attitude towards collaboration between the care providers, Patient confidence in care providers, Patient expectations, persistent ongoing symptoms, physiotherapy, Previous response to treatment, prognosis, targeted therapy, Type of interventions prescribed, whiplash

Feed enhanced by Better Feed from Ozh

The basic mechanics of gait and propulsion dictate that the extensor chain mechanism must operate in an integrated way to convert ground reaction force into forward momentum.  From a clinical perspective we are interested in the integrated activity of ankle plantar flexion, hip and knee extension and controlled but stable trunk alignment on the propelling limb.  There are a number of potential mechanisms of breakdown in this region, which can be broadly categorised as:

motion impairment deficiencies

muscle power deficiencies.

Impairment of ankle dorsi flexion range inhibits the ability of the foot to act like a pivot and allow body weight to transfer in front of the axis of the ankle joint in order to facilitate propulsion.

Impairment of knee extension effectively shortens the length of the standing leg and reduces the efficiency of forced transmission through the lower limb.  Typically in association with impaired knee extension is an increased co-activation of the hamstrings and quadriceps with the net result of a stiffening of the limb and reduction in “fluidity” of knee motion.

The next component of the extensor chain is the ability to extend the hip.  In cases where postural alignment tends to be flexed the centre of gravity remains anterior to the axis of the hip joint producing a perpetual flexion moment.  This is perpetuated by sustained hip/flexor muscle activity in conjunction with the anterior abdominal wall.  In order for the hip to function freely there needs to be passive range of hip extension and sufficient power within the prime hip extensors (gluteus maximus) to generate the propulsion.

In clinical practice impairment of this fundamental component of gait is exceedingly common and often  results in a combination of compensatory strategies.  One compensatory strategy for impairment of hip extension is to induce excessive sacroiliac torsion producing increased anterior rotation of the innominate bone.  This may subsequently produce secondary strain through the lumbosacral junction or induce a motion pattern of lumbar hyperextension in order to bring the leg behind the body.  Not only is this movement pattern inefficient but produces a high risk of tissue overload in the zones of compensation.

Clinical Thought

1. How can we detect breakdowns in the extensor chain function?

1. What are the implications of a hyperlordotic strategy for hip extension in relation to trunk stability?

1. What are the implications of anterior innominate rotation as part of the facilitatory mechanism of leg extension?

Share your thoughts and …..

Rise to the clinical challenge.
David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | One comment | Add to del.icio.us
Post tags: back extension, dysfunction, extension, extension exercise, extension exercises, extensor chain, hip dysfunction, hip extension, joint dysfunction, knee extension, low back pain, motion impairment deficiencies, muscle power deficiencies, pelvic dysfunction, sacroiliac dysfunction, sacroiliac joint dysfunction, si dysfunction spine extension, tissue overload

Feed enhanced by Better Feed from Ozh

The converse view is that manual therapy and functionally specific rehabilitation can be used directly as a cognitive-behavioural strategy to address specific patient complaints / functional impairments. As physiotherapists we need to recognise that any interactions we have with patients have cognitive / emotive connotations and there is no practical reason why physical means cannot be used to facilitate this approach as an adjunct or an alternative to psychotherapy techniques

Those who attended the “Decade of the Flags” conference in Keel university at the end of 2007 will know that primary care clinicians can now no longer hide behind professional boundaries as an excuse not to challenge patients distorted beliefs or facilitate rehabilitation programs which are tailored to their needs.

This obviously poses clinical challenges but the facts won’t go away by passing the buck.

What do you find the most challenging aspects of of this situation?

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2008. | Permalink | One comment | Add to del.icio.us
Post tags: low back pain, physhosocial, physiotherapy, psychosocial flags, rehabilitation

Feed enhanced by Better Feed from Ozh