|image from westsubpainrelief.com|
This Thursday Thoughts is really a Q&A regarding a case sent in by a frequent reader and poster to Phys I/O Forums.
His back doesn't hurt at all. Could it be that there is nociception in the spine but he only feels it in the knee? Or is the spinal motion novel enough that it calms down knee pain even though the spine is not perceived as threatened?
I don't get it and don't know how to explain it to patients. Do you know why?"
Review these - lumbar manipulation for knee pain research and attempt at CPR
- this study
- attempt at validation - some benefitted from lumbar manipulation but no change in function or strength - not able to be replicated
Before I even get into my thoughts, I want to ask some general questions to those of you who are struggling with explanations of the effects and mechanisms behind repeated motions
- what explanations do you use for mobilization/manipulation?
- do you feel that grade 3-4 are generally more effective than grade 1-2 for restoration of mobility and decrease in pain perception?
- think of pain as just a perception and not patellofemoral pain syndrome - it's just pain perceived in the knee
Reflect on the above as you read on
Here are my current thoughts on repeated motions as a treatment
- repeated motion indications are the same as those for joint mobilization/manipulation
- both have the same neurophysiologic effects
- bombarding the CNS with novel, non-threatening proprioceptive information
- in effect, giving awareness to a smudged area of the cortex that represents the area under threat
- the further into end range you get, the more input to the CNS occurs
- larger, threat free ranges are more likely to get the brain to give a green light, raising pain and movement thresholds
- my analogy to patients is walking on ice - small steps due to perceived danger, versus free full and large steps when you feel safe
For the lumbar case in question
- we all know that the area that is "referring pain" does not have to hurt
- so "knee pain" could be referred from the lumbar spine
- there is something powerful using lumbar repeated motions/mob/manipulation and improving pain and movement thresholds down the lower quarter chain
- most likely due to the peripheral innervation that starts there
- using the lumbar spine and loading it into end range (of a most likely limited range) restore's threat free ability to accept load
- threat free load is important
- if danger is perceived with load to the lumbar spine, we cannot predict where the pain will be perceived
- perhaps the knee has a bit of wrinkles on the inside, plus combined with a lack of ankle mobility, hip mobility, and lumbar loading ability, the input from that area reaches a threshold that sets of an alarm in the CNS
- restoring any of these things usually helps, but a combination of spinal repeated loading and the right education seems to be the more effective
Hopefully that does not seem to scattered, and I maintain that we know more about what is not happening in treated areas that what is - meaning little to no pure mechanical effects.
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!
Keeping it Eclectic...