Physiotherapy – Having the balls and juggling

So today has been one of those days where im left feeling like I’m lacking a whole lot of understanding after being blown out the water by some puzzling bodies. This blog post is me putting my thoughts on paper in an attempt to make some sense of what needs to be considered in our profession. With so much to consider, it seems fitting to state – Physiotherapy is not about how many balls you have, its how many you can juggle.

By balls, im talking about the variables we have to consider not only individually, but against each other. Most countries have a physiotherapy association which publishes guidelines based on what treatment has been found most effective for each clinical presentation. Very useful, but we have to ask ourselves what kind of outcome we are pursuing. From physiotherapy, one can hope to get the following:

  1. Pain relief
  2. Improved tissue healing
  3. Strengthening of a body compensation.
  4. Correction of cause (improved movement)

Of course there are many other benefits from physiotherapy, but these are what I see to be most common and interesting for discussion here.

So lets dissect our profession further. Our objective findings in vitro would show:

  • Bone structure (+ versions)
  • Joint ROM
  • Muscle physical length
  • Muscle quality + cross section

Our objective findings in vivo would show

  • Bone structure (+ versions)
  • Joint ROM
  • Muscle physiological length
  • Muscle strength
  • & the ever important… Functional use of the above.

So there are our 5 raw variables in both structure and function. Ask yourself:

  • Which do you think varies the most?
  • Which two do you think have the closest dependency on each other?
  • Which do you think causes the most issues for the patients we see?

Those questions are hard to answer, if answerable. But now we have our boiled down variables which are mind blowing if comprehended under varying potential and infinite permutations. Let us consider some rules to bring some order to the chaos of possibility a patient presents.

1. Structure governs function.

This is a pretty solid one. As Serge Gracovetsky once said ‘Human anatomy is a consequence of function’, our nervous system will rarely favour going against the grain. It will take the most energy efficient way *it knows* and exploit it. We can look at the way a patient moves and know their structural component it a baseline to what we see. Dusted on that is soft tissue length such as fascia, muscle and skin etc, all which deliver afferent information to combine with existing motor patterns for a movement output. Is that all there is to function? We wish. Behaviour also comes into the movement we see in a patient. If fatigued we move different, if in a good mood we move different, if afraid, if in pain, if anxious… we move different. So in a way we should say in addition: but our body considers its energy output/environment/body status and we move according to that.

2. That which enhances performance, prevents injury – Larry Hamilton

I like this quote as it is true, based on the assumption one enhances performance correctly. If something in the human body doesn’t function well, it will be compensated. As Jeff Moreno once said, ‘The human body is highly adaptable, which means that the human body can unfortunately be efficiently inefficient!’. The ability to compensate is amazing yes, ideal? – not always. Ideally we would like to correct the dysfunction when possible and not just strengthen a compensation pattern. But that can only happen after identifying what the dysfunction is… and so we move on.

3. Weak muscles need strengthening.

A quote by The Gait Guys really resonates well with how I feel about this: ‘You are doing your client a huge disservice if you think  you are smarter than their brain and activate muscles that their brain has inhibited for a reason’. If a patient has had a previous injury or a traumatic event then yes, by all means activate and strengthen a muscle to later integrate it back into movement. If a patient has weak gluteal hip extensors then you need to ask yourself why before you simply strengthen. Strength is specific, so we cannot expect glutes which work well in the squat, to work well in mid-terminal hip extension.

4. Short muscles need to be stretched.

As stated before in strength/weakness, this is most likely to be for a reason. Of course stretching a muscle may give relief, but in the same way massage has poor long-term resolution for the majority, there must be a reason for hypertonic short muscles. For the purpose of thought, one source I recently read advised the therapist check the contralateral side for muscle (group) weakness before treating tightness. Another thought to ponder is are many tight hamstrings due to weak lower back extensors (bilateral or ipsilateral with a contralateral crossover), if so, can we apply the principle of one example to another scenario? Short muscles are most likely serving a purpose and should be treated as a sign, not only a symptom.

5. Don’t treat the symptoms treat the cause.

Assuming we know what the cause is, it should not be that we forget the symptoms it has left behind!. Pain being the common symptom we hope to resolve, lets not forget that pain perpetuates itself as well as winds up the nervous system to propagate hypertonicity, muscle spasm, sleep loss, depression, fatigue…and the rest of the family.

6. Exercise rehabilitation works best

Just because the body can adapt, doesn’t mean it always ends in a compensatory fashion, it too knows how to get better. Exercise may be tailored to be specific, but the majority of times its far from it (try working your knee extensors without your deep hip flexors, or your deep hip flexors without your trunk flexors etc). We can train the correct muscles to gain the result, or accidentally strengthen others enough to offload the issue and still get the result. In the same way we can target the tissues accidentally. Im sure many reading this would have also read the studies finding most exercise to be just as effective as ‘core training’ when trying to strengthen the ‘core’.

The situation.

When the seed of pathology has been sown, its only a matter of time till its painful symptomatic fruits are born. When pain presents, the average physio should find it no problem to give them a rub better or stick a modality on for symptom relief. In my books, this is like pruning the pathology plant. It cuts it back, but most times not for long.

We can tell the patient to self massage to do their own pruning, we can go one better and get them to move in a better way to strengthen those phasic muscles so they may compensate more. This may buy more time but if the cause is not found, its self limiting. The patients time is up, its home exercises till their next appointment…

(After 1 or 2 sessions) …The patient comes in with the same complaints. They have been diligent with their exercises with no joy. After some more pressing and guessing, poking and hoping, we try to think what else could be the cause and generate the next best treatment. A new approach along with some reassurance which conveys something along the lines of Rome not being built in a day and we see them next week.

Note: Of course we would hope most patients would have come better by now, but this is that sequence of events which comes along in many forms I’m sure we have all come across.

Finally, here is the perfect scenario to bring back blue skies. We perform a thorough evaluation of the patient and find the root cause for complaints. We are so sure of it from experience and reasoning that we can see the smile on the patients face upon reassessment already. We expertly –enter treatment here– due to reason x, y and z and what do you know, we have a result. So what happened? If things were painful one minute and fine the next – did we reposition the joint in a Mulligan fashion? Did we release a stiff joint with some effective Maitland mobilization? Maybe re-aligned the pelvis for effective form closure? Activate the right muscles and maybe turn off the wrong ones? Did we release a trigger point? …Hopefully we didn’t just cause so much pain that after disconnecting our elbow from some tender point – life could be nothing but great.

This post is not meant to conjure up doubt, but to raise a critical view to what we are really doing and to see if it can be improved. Everyone reading this has the patients best interests at heart, and has made efforts to answer to the complexities we face. As I’ve mentioned in previous posts, do not give in to the confusing nature of our profession and assume we know what is going on.

 The less you know, the more opinionated you are. – Buddy Morris

  1. Bone structure (versions etc)
  2. Joint ROM
  3. Muscle physiological length
  4. Muscle strength
  5. Function

In my opinion the answers must lay within the above 5, so study each well and don’t just note your findings, try to interpret them.

Each one can affect the other and all make the bigger picture. If you have read David Butlers rollercoaster of professional life you will have related and had a laugh at how truly eager we are to find the key. It can take a single workshop, lecture or success with a patient to give us that hammer which makes us only sees only nails mentality. Collect your balls, examine them and don’t look at one for the answer. Keep on juggling and never think you know too much to pick up an anatomy book.

Thanks for reading, if you have any thoughts on this topic or think I’ve missed something, please comment.