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Low Back Pain during Lat Pull Down: A Movement & Pain Science Treatment Approach

10/30/2017

1 Comment

 

"Hinge points and movement deviations may not be pertinent to pain, but they tell a story about how someone chooses to load their joints and program their movements."
-Jim Heafner PT, DPT, OCS

Many therapists agree that there is no single 'best posture.' Most would also agree that we do not have 'dysfunctional movement,' but rather movement deviations. As I tell many of my patients, "No movement is a bad movement; no posture is a bad posture. To live fully, we must perform them all." Therefore, movement habits and patterns do not equate to pain. While I agree with this philosophy, we simply cannot neglect posture and movement. As physical therapists, our job is to identify positions of relief to calm down the system & provide novel stimuli to reprogram the system. In this post, I discuss my personal experience with low back pain. I discuss my assessment and treatment from a movement perspective and pain perspective. 

Posture and Movement Perspective

Last year I was experiencing mild to moderate right sided low back and right anterior hip pain that would increase while performing lat pull downs and back squats. Symptoms increased at the end-range of the concentric phase of the lat pull down and deep in the squat position. I would describe the pain as compression and pinching in both the low back and anterior hip. Out of curiosity, I took pictures (see below) performing these movements to see what was occurring mechanically.
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Picture Analysis
  • Hinge point in R low back at L2 region with side bending
  • Excessive lumbar flexion with forward trunk positioning during the squat
  • Hinge point at L2 region during lat pull down
While hinge points are common and not correlated with pain, I happened to have a hinge point at the location of my low back pain during the lat pull down. This skin fold appeared because I would hyperextend through the thoracolumbar junction during lat pull downs. As seen in the squat photo, I had considerable lumbar flexion, forward trunk positioning, and out-toeing bilaterally.* If I performed an abdominal draw in maneuver (emphasizing TrA) during any of these movements, I felt significant relief of symptoms** While I did not have any EMG done, it felt as if the lower abdominal activation allowed my anterior hip flexors to 'turn off' relative to their previous state.***

*Do not worry pain scientists, I know we naturally flex through the lumbar spine and some people naturally lean more forward depending on their tibia to femur ratio.
**Do not worry global strengthening folks, I know there is no evidence to support TrA activation.
***I won't get into the topic of inhibited vs. facilitated muscle groups in this post.

Pain Science Perspective 

I am aware that hinge points and movement deviations on a squat are not a cause of pain. As I wrote in a blog post earlier this year, "The research does not support either good or bad posture. We cannot confidently say that poor posture causes problems OR good posture prevents problems. This is because posture alone does not equal pain. Several studies have been published over the past few years that confirm pain is unrelated to our anatomical tissues. For example, 34% of asymptomatic people >60 years old have been found to have rotator cuff tears. One in three people WITHOUT SHOULDER PAIN have a rotator cuff tear. " 

However, I simply could not do enough self-neuroscience education to decrease the pain (maybe I didn't believe myself...who knows.) Despite offloading and gradually reintroducing weight to the movements, my brain continued to recognize the movements as painful.

At this point, I hit a crossroad. Do I...

1) Continually load the painful patterns to desensitize the movements
  • This would follow the pain science path of treatment
2) Take a standard postural approach- focus on proper squat mechanics, core activation during lat pull downs, hip mobility to offload the sense of anterior impingement 
  • This would follow the movement and posture path of treatment

Self Treatment

Personally, I chose to perform a combination of both options.
My top 3 interventions:
  1. Lumbar extensions
  2. Hip external rotation mobility
  3. Thoracic mobility. ​
Picture
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1) Lumbar extensions were performed to improve lumbar extension range of motion as well as improve the loading pattern into extension as I squatted. While the first few repetitions were painful, the repeated loading desensitized movement and allowed me to maintain an upright position in the squat. 
2) Hip External Rotation mobility was performed to improve the joint mobility in my hips. I perceived that tight hip joints were limiting my capacity to squat. From a mechanical standpoint, improved hip mobility allowed me to disassociate lumbar motion from pelvic motion. The increased hip mobility allowed me to maintain a neutral spine position and load through the posterior chain.
3) Thoracic mobility was performed to help maintain an upright posture during squatting movements and allow for improved shoulder mobility while performing lat pull downs. Additionally, improved thoracic mobility gave me a sense of better scapular muscle activation. ​

Incorporating Movement & Pain Science 

In my situation, combining my knowledge of pain and tissue damage with the more mechanical approach of proper alignment was very effective. Since the brain is the control center of all input and output, it recognizes when someone is using too much energy to perform a task. For example, the forward head posture is not inherently painful, but chronic forward head positioning is an inefficient use of energy. To hold the head in a forward position, the anterior and posterior muscles are not working in equilibrium. The brain must expend more energy, time, and attention to keeping the head in a forward position. It has nothing to do with pain, and everything to do with efficiency. The combination of approaches was beneficial because I brought awareness and perception to areas that needed stimulation, and simultaneously calmed down areas that were already too sensitive to movement. 

​In conclusion: the treatment approach will be different for everyone. We all think, move, and act in unique ways. Many of our daily actions are performed reflexively without thought or awareness. Bringing increased perception to a painful region while modulating their pain will allow someone to understand why the pain is occurring and how to control symptoms.
​-Jim Heafner PT, DPT, OCS
1 Comment

Specificity vs. General Lumbar Stabilization Training

10/23/2017

0 Comments

 
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Core strengthening appears to be a very abstract term in the world of physical therapy. To some, it means very specific motor control training. To others, it means planks. Several years ago, a proposed core stabilization clinical prediction rule was shown to lack validity. Regardless, due to the lack of established guidelines for core stability training, there will continue to be a variety of techniques, based on the clinician's preference.

​When it comes to lumbar manipulation, there has been a significant amount of research to show our inability to manipulation a specific segment. Even when we try to "isolate" an area, movement can occur several segments above and below. It would appear the lack of specificity with manipulation is rather insignificant, so certain patients may just respond to manipulation in general. Can the same theory apply to stabilization? I recently read a study that compared specific motor control training in the lumbar spine to high-load deadlift training. The results showed that there was no difference in strength, pain intensity or muscle endurance between the two groups. The motor control group did have better motor control and activity, but the fact that pain, strength, and endurance were similar can help us in not needing to be so specific with our exercises. Sometimes, the particular instructions we give to our patients can actually cause a fear of movement, which is something we want to avoid.

Now, I am not necessarily saying there is no point to motor control training. I would simply argue that it's not as important as we used to think. If there is a subtle pelvic motion when reaching overhead, we don't necessarily need to be stopping the exercise altogether. It may still be beneficial to establish some general patterns of motion during earlier stages of rehab in order to prevent re-aggravation during high load training. Personally, following my manual treatment (if indicated), I will start with a  couple mobility exercises to help get the spine moving. I then follow that up with some motor control training to prep for whatever movement I am going to have the patient perform. For example, if my patient will be doing a deadlift, I will prime them with a quad rock back and/or hip hinge, in order to help dissociate lumbar and hip motion with heavy lifting. My end-goal however, is to get my patient strengthening with heavier weight.

​-Dr. Chris Fox, PT, DPT, OCS

TSPT is now offering a comprehensive LUMBAR SPINE COURSE

Interested in learning more about the lumbar spine?
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This online course includes:
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    • Examination and Assessment
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  • Exercise videos for the lumbar spine
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Looking for advanced sports and orthopedic content? Take a look at our BRAND NEW Insider Access pages! New video and lecture content added monthly. 
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Transverse Ligament Test vs. Sharp-Purser Test

10/17/2017

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Cervical stability testing is one of the most important aspects of a cervical screen. While it may not help our treatment directly, it may save some people's lives or prevent significant worsening of injury. There are several key components of cervical stability testing:
​-Transverse Ligament
-Alar Ligament
​-Fracture Screening
​There is specific testing for Alar Ligament Integrity but for cervical fx screening, it is recommended to utilize the Canadian C-spine rules and Jefferson Fx test.

​The Transverse Ligament is responsible for maintaining stability between C1 and the odontoid process of C2. Without the ligament functioning, spinal cord injury is possible. While it is rare for a patient with a ruptured Transverse Ligament to present to you in a clinic, with direct access, it is certainly possible. The patient may hold their head in a certain position (avoiding positions that aggravate symptoms), to keep the injury "reduced." There are two methods that we recommend for testing the ligament's integrity: Sharp-Purser Test and Supine Transverse Ligament Test.
While both tests can be effective for assessing stability, we recommend using both. First, the Sharp-Purser Test should be used as it is a REDUCING test. That means, if a symptomatic patient presents, you will reduce their symptoms if the test is positive. While most patients won't allow you to "provoke" their symptoms with the initial part of the test, it is still important to try reducing symptoms before aggravating. Next, we recommend using the supine Transverse Ligament Test to provoke symptoms. The force is minimal, so it is unlikely to be harmful if stopped when any appropriate symptoms are produced.

​While the diagnostic accuracy for upper cervical stability and utilization of Canadian C-Spine rules is relatively high, it is not recommended to completely override clinical decision making. As always, we recommend a thorough evaluation and consideration of the evidence of each test's findings. For more information on these tests, be sure to check out the pages linked above.

​-Dr. Chris Fox, PT, DPT, OCS

TSPT now offering a comprehensive Cervical Spine Course

Interested in learning more about the cervical spine?
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LEARN MORE!
​(Save $10 with Promo: Neckpain)
This online course includes:
  • 4 interactive lectures (Anatomy & Biomechanics, Differential Diagnosis, Examination, Advanced Treatment Techniques )
  • Advanced examination video content
  • Advanced treatment and intervention video content 
  • Links to our TSPT Cervical Home Exercise Program

Looking for advanced sports and orthopedic content? Take a look at our BRAND NEW Insider Access pages! New video and lecture content added monthly. 
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PT Month Quiz: How's Your Professional Knowledge?

10/14/2017

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In honor of National Physical Therapy month, The Student Physical Therapist has compiled a list of facts, statistics, and fun information about our amazing profession. This quiz covers everything from historical facts about Physical Therapy to Physical Therapists perception on the dating app Tender! 
National PT Month Quiz
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Take our Quiz! 

National Physical Therapy Month Quiz
We hope you enjoy the quiz! Please continue to strive everyday to make the profession great. 
#getPT1st
​Jim, Chris, and Brian

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Looking for advanced sports and orthopedic content? Take a look at our BRAND NEW Insider Access pages! New video and lecture content added regularly. ​
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  • Home
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  • Insider Access
    • About Insider Access
  • Online Courses
    • Hooper's Knee
    • Physical Therapist Entrepreneur Course
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    • Return to Sport Essentials Course
  • Resources
    • Newsletter
    • Business Minded Sports Physio Podcast
    • Day in the Life of a Sports PT
    • Residency Corner
    • Special Tests >
      • Cervical Spine >
        • Alar Ligament Test
        • Bakody's Sign
        • Cervical Distraction Test
        • Cervical Rotation Lateral Flexion Test
        • Craniocervical Flexion Test (CCFT)
        • Deep Neck Flexor Endurance Test
        • Posterior-Anterior Segmental Mobility
        • Segmental Mobility
        • Sharp-Purser Test
        • Spurling's Maneuver
        • Transverse Ligament Test
        • ULNT - Median
        • ULNT - Radial
        • ULNT - Ulnar
        • Vertebral Artery Test
      • Thoracic Spine >
        • Adam's Forward Bend Test
        • Passive Neck Flexion Test
        • Thoracic Compression Test
        • Thoracic Distraction Test
        • Thoracic Foraminal Closure Test
      • Lumbar Spine/Sacroiliac Joint >
        • Active Sit-Up Test
        • Alternate Gillet Test
        • Crossed Straight Leg Raise Test
        • Extensor Endurance Test
        • FABER Test
        • Fortin's Sign
        • Gaenslen Test
        • Gillet Test
        • Gower's Sign
        • Lumbar Quadrant Test
        • POSH Test
        • Posteroanterior Mobility
        • Prone Knee Bend Test
        • Prone Instability Test
        • Resisted Abduction Test
        • Sacral Clearing Test
        • Seated Forward Flexion Test
        • SIJ Compression/Distraction Test
        • Slump Test
        • Sphinx Test
        • Spine Rotators & Multifidus Test
        • Squish Test
        • Standing Forward Flexion Test
        • Straight Leg Raise Test
        • Supine to Long Sit Test
      • Shoulder >
        • Active Compression Test
        • Anterior Apprehension
        • Biceps Load Test II
        • Drop Arm Sign
        • External Rotation Lag Sign
        • Hawkins-Kennedy Impingement Sign
        • Horizontal Adduction Test
        • Internal Rotation Lag Sign
        • Jobe Test
        • Ludington's Test
        • Neer Test
        • Painful Arc Sign
        • Pronated Load Test
        • Resisted Supination External Rotation Test
        • Speed's Test
        • Posterior Apprehension
        • Sulcus Sign
        • Thoracic Outlet Tests >
          • Adson's Test
          • Costoclavicular Brace
          • Hyperabduction Test
          • Roos (EAST)
        • Yergason's Test
      • Elbow >
        • Biceps Squeeze Test
        • Chair Sign
        • Cozen's Test
        • Elbow Extension Test
        • Medial Epicondylalgia Test
        • Mill's Test
        • Moving Valgus Stress Test
        • Push-up Sign
        • Ulnar Nerve Compression Test
        • Valgus Stress Test
        • Varus Stress Test
      • Wrist/Hand >
        • Allen's Test
        • Carpal Compression Test
        • Finkelstein Test
        • Phalen's Test
        • Reverse Phalen's Test
      • Hip >
        • Craig's Test
        • Dial Test
        • FABER Test
        • FAIR Test
        • Fitzgerald's Test
        • Hip Quadrant Test
        • Hop Test
        • Labral Anterior Impingement Test
        • Labral Posterior Impingement Test
        • Long-Axis Femoral Distraction Test
        • Noble Compression Test
        • Percussion Test
        • Sign of the Buttock
        • Trendelenburg Test
      • Knee >
        • Anterior Drawer Test
        • Dial Test (Tibial Rotation Test)
        • Joint Line Tenderness
        • Lachman Test
        • McMurray Test
        • Noble Compression Test
        • Pivot-Shift Test
        • Posterior Drawer Test
        • Posterior Sag Sign
        • Quad Active Test
        • Thessaly Test
        • Valgus Stress Test
        • Varus Stress Test
      • Foot/Ankle >
        • Anterior Drawer
        • Calf Squeeze Test
        • External Rotation Test
        • Fracture Screening Tests
        • Impingement Sign
        • Navicular Drop Test
        • Squeeze Test
        • Talar Tilt
        • Tarsal Tunnel Syndrome Test
        • Test for Interdigital Neuroma
        • Windlass Test