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Message Board>
hnp's
jen
56 posts
Jan 16, 2010
6:50 AM
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would like everyone's opinion on the fab 5 motions for a patient with a mri indicating lumbar hnp: concerns using any motion? best results with one motion vs another?
collecting info and philosophical comments-so i would appreciate any and all opinions (whether you treat this regularly or not)
thank you so much to all who help satisfy my curiousity!
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Tom Dalonzo-Baker
139 posts
Jan 17, 2010
7:12 AM
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Yes - don't use the motions that hurt :) Best results from motions that don't hurt.
If the FAB 5 are flaring them up - use the Tender Point Collapse on them to downregulate the autonomic nervous system (get the tender points reduced) and then the body will stop guarding so much and will be ready for the FAB 5 again.
Anytime someone is not responding appropriately to the FAB 5 their body or mind is in a state of flight or flight (upregulation). I do the FAB 5 first, keeping basic however I may add chunking, extreme end range, and some "connect the whole body motions" like we do with the twist (letting whole body twist). I don't try to do many, but if I keep getting - no improvement or very little after no improvement, then i know they are upregulated. I look for tender points and then I push on them. I elicited the jump response and follow that jump response where the body is moving to get away from it. In other words now tender points are simply telling you where the body quickly wants to move. Connect a few of those tender points together and the entire body will move into a direction of injury. Very cool stuff.
HNP should not be treated any different than a regular patient. Their warning signs (pain) are much more intact and so you & they hear them LOUDER.
Hope that helps.
Tom
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jen
58 posts
Jan 17, 2010
8:45 PM
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course it does-just wanting various opinions and experiences
i am really looking forward to more on this Tender Point Collapse
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AKPT
7 posts
Jan 22, 2010
10:18 AM
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Jen,
For some reason, I have had several pts w/ HNP the past 6 mo. MRIs clearly show this and their MDs clearly tell them "no rotation at any time". This makes me a bit jumpy when performing TW.
Though TMR approach works the good side and avoids the injury-producting or "bad" side, I'm also concerned about the unwarranted liability of pushing into a clearly-stated contraindication. Our current legal system represents swaying juries, not in fact-finding or any search for truth. Due to that, I'm leary of allowing significant movement into TW. However, I still test for and treat with TW, but in a modified and fully safe manner.
Once the good/bad sides with TW are slowly and carefully determined (usually performed in supine), I have the pt isometrically treat toward the good from a midline position; I always start out with low force and build intensity only as their body allows (better less than more). It tends to produce great results but also protects them physically and me legally. Assuming success with above, they can do HEP by isometrically pushing into side of couch, a wall, a willing family member, etc.
I sometimes find the LR is touchy on the good side (often terrible on bad side). If so, assuming pt tolerance, I sometimes gently hold it toward end ROM while asking pt for continued feedback on the other side. If pn lessens as opposed to worsens, I sometimes hold it with gentle AAROM or even passively for up to 3 min at a time.... I only use this modification in cases where standard LR doesn't work.
Deep breathing often works well during releases.
Having pts "breathe into the pain" often allows for better release and can effectively clear many localized muscle cramps for even better TMR results. Otherwise, the cramps can get in the way of progress and they often obscure pt's ability to distinguish between acceptable and pathalogical pn.
Lastly, due to a huge prevelance of SI dysfunction, I carefully assess for this using mostly DonTigny techniques then, as appropriate, adapt to TMR (good side treats bad). Due to the influence of iliolumbar lig on L4 and L5, an SI dysfunction will by necessity affect the L spine. Which started first? I don't know or care... they both need to be treated out to get rid of pain and dysfunction. Will the HNP heal or will they need surgery? Time will tell but releasing tightly clenched muscles and postural dysfunction can only help.
Jen, those are a few mods that have treated my/our patients well. Since both of us in our office use the same and/or similar techniques, we've compared notes and found these small points to produce big results.
Now, show us your cards....
Todd
BTW, I'm looking forward to looking into TPC, as well. Tom, once again, you've piqued our curiosity.
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AKPT
8 posts
Jan 22, 2010
10:37 PM
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"I look for tender points and then I push on them.... Connect a few of those tender points together and the entire body will move into a direction of injury."
Tom,
I'm trying to see things through your eyes. Do you mean by the above that we could follow several tender points and push into them to cause the body to "fold" into a preferred position? If that is the case, should we then fold the body even further into that movement pattern for positional release? Would you make that active by contracting into it or passive, as with SCS (hold 90 sec)?
Oh great one, please cast some light into our darkness.
Todd
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Trixie
11 posts
Feb 04, 2010
5:44 PM
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hey tom that is great about the tender points, I did not catch that last time, the reason for using it was the ANS system
thanks
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Tom Dalonzo-Baker
148 posts
Feb 05, 2010
8:27 PM
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AKPT - I try to exaggerate the tenderpoint collapse motion just slight. I have been treating it by having the patient do repetitions, until it just isn't Reflexive acting anymore. About 10-12 reps. The more they can connect the whole body into the motion the more release you have. This takes some cueing and even practicing on yourself to feel it. Often times if I push on a tenderpoint in someones chest they just want to move their upper body. Until I push hard as heck and their leg kicks up do they realize that the whole body is connected. I will say this - even just collapsing part of the body the patient typically will respond as liking that motion. Retest the issue after and you should see an easing of motion and issue improvement. Their general well being will be more relaxed.
Hope that helps- if not ask me more stuff and I will do my best to describe it. Will get a video up eventually of it.
Tom
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jen
61 posts
Feb 12, 2010
5:49 AM
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so i have had other coworkers question the sanity of using leg raise and sit to stand and twist for hnp's
i have not been good at correlating how many of my pt with a dx and symptoms of hnp respond best to which motion-i know i have used the opposite leg raise on a few pts with positive slr testing and had great results however maybe they wouldve had just as great results using a 'safer' ex like the arm raise or a hip extension
to be honest-i never considered the sit to stand unsafe for hnp (just possibly more exertional) and i havent worried about twisting
i guess i have most frustration with the thought of limiting motions performed based on a structural dx
isnt it reeeeeallly hard to definitively dx the tissue causing the pain in most cases-and if so, shouldnt my treatments be primarily led based on symptomatic response? of course the structural dx would be a nice thing to know to see if it correlates to the physical exam as well as how the symptoms respond to various treatments but....i dont want to feel scared to work carefully into some direction of motion just cause they have a hnp, or spondylolisthesis, or spurring-i want to limit directions of motion or treatment based on how it feels during and after that movement...
shoot-ive had people flare up with radicular symptoms with simple stabilty ex keeping the spine and pelvis neutral-so i find another way, but there is no 'contraindication' to neutral spine stabilization ex right? so if they do their good side for a sit to stand, the bad improves and all of a sudden nerve tension improves and they can perform full torso motion with no pain-what did i do that was gonna worsen that hnp? seems like i made it better
to be honest- in the beginning with pts, i really like finding the motion with the biggest asymmetry but sometimes i perfer finding the best of all the good-er motions and seeing what the best of the best in the body can do for that person that day
those are my cards-really not much, just the frustration with the definitive contraindications regarding certain structural issues despite the continued lack of definitive studies (yes yes i know there are some that have found very strong relations-but lets talk comparing B flex/ext vs unilateral flex/ext, active vs passive, etc...)
ps-found one interesting study, actually many, but this one in particular found posterior migration of the nucleus pulposus with flexion in a healthy disc, howEVER-in discs with mod to severe deg changes, flexion resulted in ANTerior displacement of the disc material and extension pushed it posteriorly...now dont we find that the majority of people have some kind of degenerative changes in the lower lumbar discs? if so, maybe flexion is not such a bad thing? anyhoo-just one study, but i thought that was interesting given all ive been taught about disc mechanics (cause that wasnt ever suggested)
shall i stop thinking out loud now? yep
happy valentine's weekend to all
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bjones
26 posts
Feb 23, 2010
1:27 PM
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Jen...boy do I owe you a phone call! In general the diagnosis doesn't really matter. A "diagnosis" of an HNP does not mean there is one. An MRI that shows an HNP does not always mean that it is symptomatic.
Most of the Dx may not coorolate clinically. If you get a reproducible neuro compression/tension sign you may want to be more cautious.
By reading my stuff everyone knows I start with the twist and arm raise with my back patients. If I need more from there I usually go in this order: standing hip rotation, single leg squat, leg raise, quadriped hip ER.
Just some ramblins'
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AKPT
10 posts
Feb 27, 2010
10:41 AM
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Jen,
For clarity on what I stated above, like Tom and Bill, I pay much more attention to the empirical results of tests/Rx than the theoretical "meaning" of Dx. I often term Dx as "tunnel vision with myopia". While it may reveal a breakdown point, it most often sheds zero light on true etiology, that is, the actual cause of the injury/breakdown. Furthermore, what we receive as "the Dx" often isn't even the site of pain/problems, especially with spine issues.
However, since we took TMR 3 together, I know you are off training wheels. My explanations were for those difficult, neurogenic cases that we all struggle with. There are no "do 2 x 20 of these" or "stand here and do this" formulas but rather a lot of tweaking... with fear and trepidation. That's why many of us appreciate this forum. At a certain point, beyond the structure of the F5, S6, their variations, and other techniques, there's an art to finding what works for the difficult patients. And that's what jazzes many of us... getting success out of what would have been failure preTMR.
Bill,
Speaking of tweaking, is there anything special to your standing hip rotation or quad ER? For hip rot, do you mean S6 version of 90* hip flx or from neutral flx? For quad ER, do you mean dog at fire hydrant?
Todd
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Tom Dalonzo-Baker
151 posts
Feb 27, 2010
11:15 AM
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Bill - you use to have a youtube video of the external rotation. I have had people request it. Can you link us to it.
Tom
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jen
65 posts
Feb 28, 2010
3:14 PM
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so are you guys saying that, if someone came in and had horribly yucky (medical terminology) left leg raise and the right side was really nice-you'd be just fine doing the right side with either reps or holds to see if you could fix the left yucky side?
i would-but others do disagree
(the more you all get to know me, you will find i just want to be told im right in my judgement-but not when im wrong in an assumption)
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bjones
27 posts
Mar 23, 2010
7:10 AM
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Todd...nothing special. We were using ER and IR for the hip rotations but have "found" that ER works very well for getting back lumbar ext (1st) and flex(2nd). I haven't used IR in a long while but that doesn't mean I wouldn't...The quad ER is the dog at the fire hydrant.
Tom/Todd...here is the you tube link:
http://www.youtube.com/watch?v=Mn5T21NmyYg
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