Thursday Thoughts: Even More End Range Spinal Loading | Modern Manual Therapy Blog

Thursday Thoughts: Even More End Range Spinal Loading

This Thursday Thoughts is as much as a Q&A Time as it is to write down my thoughts on a particular subject. A regular reader recently emailed this very good question.

During a recent discussion with a colleague we got on the topic of end range loading to decrease threat, etc. I wanted to get your thoughts on how end range loading is beneficial if, according to what we have learned about the interforaminal foramen, we are compressing the nerves (which is bad right? due to wearing away of the myelin creating AIGS, etc.). Or does the wearing away of the myelin only occur in chronic cases or compression? Thank you in advance for your help!

Here are reasons why I think repeated end range loading work

  • the directional preference is often a novel movement that is limited, but not normally associated with pain or limitation
  • getting to end range stimulates joint mechanoreceptors providing a similar proprioceptive bombardment to the CNS that joint mob/manips do
  • full movement through the joint's range is now diassociated with pain, instead of being associated with the perception of pain (disassocation being a psychological association, not physical isolation of one body part from another)
  • works as a graded exposure that eventually decreases stretch, threat, and pain perception over time

I recently did an online consult that had low back pain on the right side for 15 years. He is only 31, we found that his directional preference seemed to be SGIS to the right. Even though he sitting tolerance on hard surface and his motion improved, he was apprehensive about performing end range loading repeatedly throughout the day. He was concerned about the thought viruses he caught from radiology and repeated explanation about discs and degeneration.

This is how I handled it

  • I flexed my elbow to end range and overpressured, then asked, "If I did this 100 times or repeatedly throughout the day, do you think I would cause further degeneration or elbow breakdown?"
  • he answered, "No."
  • I told him every repeated movement strategy is based upon using movement you have built in, and reminded him of the stop light rule
  • I explained to him that tissues do not change immediately any more than his resistance training grew his biceps immediately
  • I also told him to email or contact me ASAP with any concerns or changes and I would modify the resets to mitigate the threat association

In essence, this also answers the Q&A from above. The reader is obviously doing his homework, looking at peripheral concerns like an AIGs, etc... those things happen (although typically not on nerve roots), but repeated motions are no more dangerous than any movement with passive overpressure. Every area of the body has built in available range, and sidegliding should not cause myelin wear from foraminal encroachment on a nerve root. The stop light rule is what matters, not the pathophysiology which we cannot change as rapidly as symptoms are modulated.

Keeping it Eclectic...

 

 

 

4 comments:

  1. Dr. Ben Ness, DPT, Crt MDT, DNMarch 26, 2015 at 11:38 AM

    This has been my biggest struggle after being Mckenzie Certified (MDT). I struggle, as I think many do, with the "Lumbar Dysfunction" syndrome since the treatment is repeated end range loading into the painful direction (e.g. repeated bending, or pressups). I can understand this from a tissue remodeling stand point but where I struggle is the CNS. They are already on a higher alert level regarding their back or they would not be in my office. Now I tell them, go away and do something that will raise that alert level 5-10 times, 3-4 times per day. I guess it comes back to the stop light rule and being very good to educate them on are you truly "Worse" after or does the pain just "Increase" then return to baseline. This is probably why you need to see these patients more frequently at first to check compliance because nobody wants to go off and "hurt yourself, 4-6 times per day". I guess once again it comes down to the stop light explanation, "Green Light" (Decr. CNS threat), "Yellow Light (Temporary increases alert level then return to baseline", "Red Light" (Increased Alert Level that does not return to baseline". I just find that compliance from patients is not as good and this is when I end up doing some IASTM or Dry Needling in the clinic to decrease that threat level into the painful movement and then send them away "hurting them-self" frequently. Thanks for all the great info every week!!!

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  2. The way traditional MDT handles dysfunction is in many ways a disservice to the patient. It is absolutely true that you cannot rush tissue deformation. That does not mean that manual therapies, pain science education and other very useful modalities cannot modulate threat and pain perception to improve patient compliance. End range loading for dysfunction is most likely not needed as the tissues take care of themselves with repeated movement once threat is removed. They just have to keep moving, but not to end range pain, yellow light, repeat until you're better.

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  3. Excellent discussion Dr.E. This a serious clinical reasoning nugget

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