I don’t know about you, but I’m a consumer of podcasts. I love to gain knowledge, information, and inspiration from this form of media. I was recently listening to an old episode of the The Joe Rogan Experience Podcast and thought this was worth sharing. What are your thoughts? I’d love to hear them!
They’re like crabs in a bucket. You know what crabs in a bucket are like? You have a bunch of crabs in a bucket and one crab tries to get out of the bucket. Then, the other crabs grab him and pull him down! That’s what always happens.
That’s the number one problem with the world… is crabs in a bucket. The number one problem with this world is people, instead of being inspired, they look to criticize. People, instead of looking at someone who works hard and does something amazing… and looking at their own life they find fault or they find weakness, or they find themselves not to add up… not to measure up. So, they get upset and instead of finding that inspiration and saying “You know what? I do have a belly, I do need to get to the gym. You know what? I do drink too much, I gotta stop doing that.” Instead of that, they just start shitting on this one thing that causes them to feel insecure. Not even realizing that that one thing has the potential to empower them.
– Joe Rogan
I think the on-going challenge is to get better at how I speak to my patients, how I educate them, and how I help them understand their condition. Maybe how I motivate them. All of that is a little bit of the art of what we do. Trying also to look to the science of what are we supposed to be saying, or what sort of things should we stay away from, in terms of our explanations. Are we doing harm with how we’re explaining what we think might be wrong?
– Ken Olson
Welcome back everyone! This conversation is with Ken Olson. If you are at all active within the manual (physical) therapy community, or have attended a conference of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT), you have likely heard of Ken. He has been heavily involved in all depths of the AAOMPT and the International Federation of Orthopaedic Manual Physical Therapists (IFOMPT). Ken is past president of the AAOMPT and is currently the president of IFOMPT. Ken also is co-owner of Northern Rehabilitation Physical Therapy Specialists and has multiple clinic sites in the Northern Illionois area. If you’d like to learn more about Ken and what he is up to, check out the links below.
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Tuning in to the patient and asking the right questions, then asking the right follow up questions. Some of those skills, I think, for the expert clinician, that’s where the development often times lies… is with that interaction with the patient.
– Ken Olson
Links of interest:
American Academy of Orthopaedic Manual Physical Therapists
International Federation of Orthopaedic Manual Physical Therapists
Northern Rehabilitation Physical Therapy Specialists
Manual Physical Therapy Of The Spine
Welcome to our first guest post on the Forum! Below, you will read about a recent complex case that our previous podcast guest, Diane Lee, managed with some sound clinical reasoning. She utilized her approach of the Integrated Systems Model and talks about how that was used for this patient. If you’d like to listen to the podcast episode we did with Diane, you can find that here. Leave Diane and myself a comment below and let us know what you think (you can also do that on our social media accounts as well)!
As a MSK physical therapist, how do you assess and know when to treat the pelvic floor? Or do you?
Let me start with a short case report. This will highlight why I feel that every clinician must have tools to assess every muscle and know how to determine if it is playing a role, and if so, what role? This includes the muscles of the pelvic floor. Yes, there are clinicians specially trained to assess and treat the pelvic floor and they are often guilty of not assessing and knowing how to treat the foot or the cranium, both of which can play a huge role in the behaviour of the pelvic floor. So, the story first, then some anatomy and common relationships I see in the clinic. If you want we can talk about the evidence, there is a lot, but let’s stay clinical for now.
In January, a long-time client who lives 1 hour from my clinic developed insidious onset pain over her right medial knee when walking. Rest did not reduce her pain, so she sought local care and unfortunately got local treatment to her knee. ‘Some kind of rubbing’ were her words. The treatment didn’t work so she saw someone else. The second therapist noticed that her hips were really ‘stiff’ and confidently told her with minimal examination that he could ‘fix her in no time and you will be snowshoeing by the weekend’. One session of dry needling to her gluts, tensor fascia lata and adductors of both hips was given and the result was that she couldn’t walk the next day or for 10 days thereafter. He didn’t respond to her email when she contacted him to say she wasn’t snow shoeing, let alone walking. She didn’t go back, found him ‘cocky’ which I later found were an interesting choice of words.
She decided to drive the hour for a whole body/whole person Integrated Systems Model assessment. Understanding the relationship between, and within, body regions and systems (neural, articular, myofascial, visceral etc.) and the consequences of impaired function of one region/system on another is complex. Many health practitioners specialize in body regions, and/or systems and treatment is often based on the practitioner’s training and experience. However, this reductionistic approach may not be optimal in that each body region is not only an integrated system within itself (i.e. comprised of many differentiated yet linked parts (Siegel 2010)) but is also integrated, and interdependent, as part of the whole body/person. No studies have correlated persistent pain anywhere in the body to a consistent impairment (Clauw 2015). Therefore, in persistent pain conditions such as low back pain, metatarsalgia, TMD, headache etc., understanding what body region and system should be treated requires an individual clinical reasoning approach. This is true whether the pain mechanism is primarily nociceptive, nociplastic, or neuropathic. The Integrated Systems Model (ISM – Lee & Lee 2011, Lee 2015) is an evidence-informed, clinical reasoning approach that embraces, and enhances, the concepts of the regional interdependence model (Sueki et al 2013).
Back to the story. I asked her more questions. What has changed in your exercise/activity program? “Nothing” she says. I reply “And nothing has happened to you, i.e. no trauma”? No. She had no idea why her knee and now both her lower extremities, pelvis and groins were aching and her hips were so ‘stiff’. She had X-rays taken and was told they were normal.
ISM begins by choosing a task that has meaning. For her, walking was a meaningful task. To be able to walk efficiently, one has to be able to stand on one leg and step forward with the other. So the examination began with a standing positional screen and the step forward task (left and right leg was the screening task evaluated). Analysis of the whole body in this task for optimal alignment biomechanics and control was done.
Both of her hips were not centered in the acetabulum in standing and failed to center in either the left or right step forward task.
The left and right SIJs were well controlled in both standing and the left and right step forward task.
There multiple thoracic rings translated/rotated, which suggested her thorax was compressed; however, no correction of any of them improved the alignment of her hips in standing nor the biomechanics required for a step forward task.
In an ISM assessment, further assessment (active and passive mobility, active and passive control) is done on what is called the driver. The body region where the greatest number of impairments are improved when the alignment, biomechanics and/or control of the driver is corrected. For this patient, the only correction that improved her standing and step forward task was a hip centering correction. So the hips were considered the driver and body region for further assessment.
Both hips were incredibly limited in active and passive flexion and rotation (both internal and external) and the end feel on passive testing was neuromuscular, not articular. When the left or right femoral head was passively centered in the acetabulum and then slowly released, the vectors (usually muscles here) that are compressing the hip can be determined and prioritized (see the video accompanying this post). This test is adapted from the Barral concept of ‘load and listen’ for those of you familiar with Barral’s work and methods. On release of the passive hip correction (this is done in supine), the first vector of pull was strong and medial, more medial than the adductors and lower than the lowest transverse abdominals (transversus abdominis and internal oblique). The next test is to palpate the muscle whose anatomy fits with the location of the pull – this would be iliococcygeus here.
External palpation of iliococcygeus on the left and right revealed a very tender over-active muscle. Now the impact of the dry needling session made sense. The reactors to the problem (gluts, TFL, adductors) were treated, not the cause.
So I asked “Have you been experiencing any change in your continence or pelvic floor since I’ve seen you last”? “No” she says, “because all my friends are becoming incontinent (she is over 60) so to prevent this and having to wear Depends like they all do I have been doing tons of Kegels every morning for 15 minutes”.
“When did you start this routine”? “Last fall”. Remember that her knee pain started in January. “Have you been relaxing your pelvic floor muscles as well or just contracting them”. “Why”? she asks. “I thought you were supposed to contract your muscles down there and hold your belly in always”. No wonder her hips are so compressed! The pelvic floor myofascial sling is continuous from one greater trochanter to the other. Take a look at the MRI below. Iliococcygeus originiates from the fascia of the obturator internus thus forming a complete sling of muscle/fascia from hip to hip. Over recruit your pelvic floor and your ‘hips suck in’. You can try this on yourself in standing. Relax your pelvic floor muscles while palpating your left and right greater trochanter, then contract your pelvic floor. You should feel the greater trochanters approximate towards the midline. Can you imagine what this would feel like if you kept this contraction on all the time. Try this, squat with your butt way back and the move your hips into medial and lateral rotation. Stand back up. Contract your pelvic floor, keep the contraction the squat and repeat the hip movement. Much less, right? This was my patient.
She just needed Shirley Sahrmann’s advice – Stop doing that!! But in a professional way.
So, I provided her with some education on how to get her pelvic floor to relax (co-ordinated with her breathing of course) and her hip mobility was 75% restored both passively and in the squat task I had you just do. Her femoral heads centered in standing and in the step forward task but ONLY when she focused on keep her pelvic floor relaxed, her groin pain disappeared immediately and she is a bit blown away that she has caused this by trying to help herself. Habits matter, strategies matter and looking at the whole person and getting the whole story is critical.
Now she has to undo the habit. If she is diligent, I don’t think it will take more than 30 days now that she understands how the pelvic floor muscles work and why just doing Kegels for the hell of it is not such a great idea if you don’t also practice letting go.
This is not new information but the message is not reaching the public nor is the importance of having some tools in your tool box as a MSK clinician to assess and treat the pelvic floor. Two excellent PTs missed this because they didn’t know how to assess the pelvic floor and its relationship to the hip (let alone the foot, thorax, cranium etc.). Nothing exists in isolation, everything is connected and in relationship. I’m sure they see lots of people with pelvic girdle pain, hip and knee pain, foot pain and even headaches and are missing an essential component of the picture by not:
So, where to start? If you don’t work with ultrasound imaging and you have trained manual therapy hands, it’s not hard.
Next – let’s talk about pressure systems and why the pelvic floor is more often a reactor to other impairments – that wasn’t my patient’s story here, her pelvic floor was the actor, not the reactor and the listening on passive correction and release of the hip was the key test that revealed this.
If you would like to learn more about the Integrated Systems Model, please visit www.learnwithdianelee.com
In the following video, we show an update to a different way of mobilizing the AC joint than you might be used to. You can see that video here. That previous video was something I came up with in the clinic. However, this video is an adaptation of a technique that I learned from Erl Pettman of NAIOMT. I’ve been more successful trying it this way, so I’ve stuck with it. So, take a gander and give it a shot for yourself in the clinic. Then, share it and write a comment here or on our social media accounts. Enjoy!
“When we got to see them [pioneers in the field of manual therapy], what I realized was, they all asked the question ‘What if?’. And that ‘What if?’ question normally came when they made a mistake with a patient.”
– Jack Stagge
“Very few of them were full of themselves. The majority of the ‘greats’ that I was around felt that they were given a gift, and felt that they weren’t that special… they just didn’t stop looking.”
– Jack Stagge
“As a profession, we have two kinds of people in physical therapy. Those that have a job, and those that have a profession. If you’re going to be a professional in anything, I don’t care what it is, it’s going to take more time and more effort… and sacrifice!”
– Jack Stagge
Welcome back everyone! This conversation is with my friend Jack Stagge. As you will hear, Jack has a lot of training with some of the best in manual therapy history. You will also notice rather quickly that he is a wonderful story-teller. As with many of our other podcasts and conversations, Jack has incredible insight when it comes to life as a professional, as well as balancing that with personal life. One unique aspect of our friendship is that I’ve gotten to know Jack somewhat personally for a short time as I was a student intern and he was my clinical instructor. So, I can personally attest to Jack’s skill as a clinician and how great of a guy he truly is. Please enjoy this conversation with Jack Stagge!
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“As a profession, we are the most gifted. We have a lot of scientific backing… we’ve been gifted with this huge thing! […] We have the ability to impact people on all levels. Physical, emotional, spiritual, whatever! […] Beceause we give all the time, there’s a giving and a connection. We can make an impact on a person… a whole person.”
– Jack Stagge
“As a therapist, always be looking for a place you can give and get nothing back.”
– Jack Stagge
Links of interest:
International Manual Therapy Seminars