He also has written a recommended nutrition book called Performance Eating . Click on Picture to check it out!
Bill also has a blog athttp://jonesercise.wordpress.com/
The Earliest Mini-Case Studies are at the bottom.
What I Did On My Summer Vacation
Actually I was visiting some relatives. And, as most PTs know, while visiting relatives “things” tend to pop up. This time there were three people to play with.
First, a female in her early 20’s, with “back trouble” since she was very young, single digits. Interesting to me because I can’t remember anything of any significance that long ago. Back stuff! That’s the easy stuff!!
Typical things with backs is they don’t move well. If it is an acute episode they may not
She bent forward and could only go to her knees comfortably. Bending backwards she had a little extension but not much. This was a good day. So I had her do some twists, easy side of course. I always have them do 3 sets of 15 seconds then retest the harder side. It’s always better than it was and this time was no exception. She then stands up, bends to her mid shins. She got a little more extension. I then had her do the arm raises (cause that’s what I do). After 3 sets of 15 seconds she touches her toes and leans way on back.
Next, a woman in her late 60s had (B) knee pain. Her pain was vague. It usually bothered her after walking for 30 minutes. Well I didn’t want to go for a 30 minute walk. I asked her if just straightening out her knees (extension for those that still like medical terminology) bothered her. They did…but “not much”. I had her walk. She said it would get worse but it “just didn’t feel normal”.
She said she had had (B) total knee replacements a few years ago and was told the components were the wrong size. She was about to undergo a revision in a couple of weeks. Most folks I’ve seen had a lot more pain with bad fitting components. I was kinda thinking that she was just told this by a different doc but…not my fight.
So had her do the twists. She straightened her knees “easier” and walking “felt better”. I had her do the twists for two more sets of 3, checking between each set of 3. After her last set she said her knees felt fine, no pain. Her walking was over “80% better”.
I certainly hope she doesn’t keep her knee surgery appointment!
And last, but certainly not least…
What I did not expect to find was someone with so many problems… About 3 months ago a male in his mid-40s started to have “tremors” in his legs and arms. The right side was worse. There was no injury. This continued to progressively get worse and then other things mounted up. He said he had always had low back problems but now it was really getting bad. His thoracic area was now bugging him even more. He had to start using a cane for balance and because his legs “were weak”.
He walked with a flexed spine and short steps. He was wearing boots for ankle support. He was avoiding using a heel toe pattern because it shot pain from his neck to his right hand. He had trouble sleeping.
When I asked him to get out of bed…it took five minutes. Yep…five minutes. Doesn’t I just wanted a beer at this point…but I digress…
He had already had and ortho and neuro workup. They couldn’t find the cause of his pain, tremors, gait deviation, lack of strength, etc. He did see a PT for a period of time. The guy first started with…you guessed it…prone on elbows. He said his whole body would shake trying to do it. I told him at this point that’s forcing a square peg in a round hole…won’t happen. At least not comfortably…
While he was seated in front of me I had him dorsiflex his feet. His right was tighter than his left. Comparing both sides as we moved up: his knee extension was tougher on the right, (interestingly) his left hip flexion was tighter than the right, and his right shoulder flexion was harder than the left.
I told him I wasn’t sure how much of a help I would be but that he would be moving better in some areas when we got done.
What do you think I did first? Yep, twists…3 sets of 15 seconds. Everything got better. Yep, every single thing. Starting with the right ankle and working up. His walking was better but not great.
We did the twists for two more sets of 15. Everything got even mo betta!! He could walk
Things were leveling off so on to the next exercise: Arm raises. His right was still tighter than the left (but better than we started). He said he had broken the collar bone as a teenager. So we did the usual 3 sets of 15 seconds…did it twice. Things were still progressing and he was satisfied. Everything was “80 – 90%” better.
I wasn’t so satisfied. So I added one more exercise: the leg raise. I wouldn’t have done that to start off with but since he was moving so much better I figured why not? Result: Everything was “95-100%” better. His walking was normal. No deviations, no cane, no shooting pain down his arm. I asked him to get back in bed and out again. Took no time at all…normal. Then he said he wanted to “Check something.” He laid on his belly and did prone on elbows without a hitch. Then he laid flat on his stomach with his right hand under his head.
He said he hadn’t done that in over 20 years…
This entire process took just under 30 minutes.
Later on he caught up with us on the beach…wearing flip flops…
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70+ y/o minister. Still works…and works and works and works. A lot of people don’t realize the amount of stuff these guys have to deal with. He was working out in a local gym about a week ago. He said he felt great but the next day he was stiff and in pain. Saw an orthopod that I know and got a diagnosis of “facet syndrome”.
(Bill’s Soapbox: Lumbar strain/sprain, low back pain, Lumbar/SI dysfunction, facet dysfunction, facet syndrome…to me these labels are basically the same: a stiff back!)
Pain: 9/10. All the pain on the left side. No reproducible neuro tension/compression signs. My label (if I have to give one): Left lumbar/SI dysfunction.
He could bend to his mid thigh and had almost no extension (probably sounds familiar by now).
I give him my major two exercises (you know what they are)…2 minutes later and he can touch his mid shins and a lot more extension.
2nd visit a week later: “Almost no pain”… “1 or 2/10”. Now he can bend over and touch his ankles and has full extension. His wife came in with him to say how much better he got in such a quick time…and they both want to know when he can get back in the gym!
3rd visit…well there wasn’t one technically. He called on the phone to say he had no more symptoms and was back in the gym doing whatever he wanted to do!
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Male, late 20’s. Has had some problems off and on since a MVA 10/09. The current exacerbation has been for about 2 months.
(B) LBP, left > right with left leg pain to the foot, constant and worse with sitting or movement. Works as a machinist.
MRI: DDD, small disc protrusion, (B) facet hypertrophy: left > right with “mild left foraminal stenosis”.
He has no reproducible neuro tension/compression signs.
My Label (because PTs give ‘em): Left Lumbar/SI dysfunction.
He could only bend to his upper thighs. He had a decent amount of extension. He couldn’t side bend to the left.
He got 2 exercises. He got more motion. He got less pain. He did…wait for it…it’s coming…it’ll be great…seated rotations and seated arm raises!!!!
So the after the first day of therapy he was able to bend to his knees, side bend (B) without symptoms and had full extension.
2nd visit: Says he feels better overall. Still has some symptoms “but not all the time like before”. He lost a little ROM but we got it back after “cleaning up” the exercises. He was doing reps of 20 instead of holding for 20 seconds.
3rd visit: No pain. Said he could now do anything he wants. Able to put his palms to the ground!
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Male, early 60s. Retired military. Referred to me with a diagnosis of “simple back pain”.
Far from simple…HTN, arthritis, DM, right THR, left TKR, back surgery x 2. Says the last back surgery was in 2007 and the knee was done 2008. The back and knee have still been bothering him the entire time. Has another appointment with the knee doctor in a couple of weeks.
He couldn’t do seated hip flexion on the left…just couldn’t pick the knee up. Could only bend forward to his upper thighs and no lumbar extension. Could barely get out of the chair in the lobby.
My label: “Left lumbar/SI dysfunction”…I may have to come up with a different label.
So what am I gonna do?
2 exercises: seated rotations and the seated arm raises…again!
Results day one: Could bend over to his knees and had a little bit of ext.
Day two: He gets out of the chair easier. Still makes a groan.
He tells me he is doing better. Says when he left the last time and got in his truck he realized that he was already doing better from the short period of time he was here.
Nice to hear that kind of stuff.
So today he is able to bend over and touch his toes! Extension is there! Says his knee is feeling fine. He says his biggest issue today is “getting out of the chair without making noise because I’m used to making noise”.
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Female, 50s, with right low back/lateral hip and lateral thigh pain for 8 months…and getting worse. She hasn’t been able to perform any housework or cook for over a month.
She can bend to her upper thighs and has almost no extension. Sidebending to the right is painful. No reproducible neuro tension/compression signs. MRI: degenerative changes w/o compression. XR of back: degenerative changes. XR of hip: Negative.
Her label from me: Right lumbar/SI dysfunction.
Her treatment…seated rotations and the arm raises.
Her result…flexion to the shins and great extension with pain dropping from an 8/10 to a 2/10.
2nd visit about 2 weeks later: No pain. She says she is back to cooking and cleaning. She can now bend over and touch her toes. Says she hasn’t felt this good since Christmas 2 years ago.
Christmas came early this year!!
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In store this month: a doctor (“hamstring pull”), a cheerleader (HNP), and a couple of other guys over 50 (annular tear, DDD).
Doctor (MD), late 50’s, calls me up one morning and says he pulled his left lateral hamstring. Says he’s not sure how he did it but the leg has been bugging him for over 6 months. He says most of the time it isn’t too bad but when he runs or does anything active it flares up again and now he hasn’t been able to run for close to 3 weeks. Asks me what to do? I tell him to stop by at the end of my day.
He comes in no visible distress. After going over his story again I tell him I want to look at his overall motion.
No knee instability. As far as other movement issues go he can bend over and touch his toes but the hamstring “catches” when his hands are at his knees. So now I have to tell him to back off and not force the issue. Leaning backwards is “stiff and tight in the back”. When he does a sitting SLR he feels the lateral hamstring just before knee lockout.
Hmmmm…what to do? Ultrasound? Ionto? Moist Heat? Ice? E-stim? Massage/Manual Therapy? Hamstring stretches or strengthening?
Hell no! Seated twists and arm raises!
After doing 3 reps of the twist and arm raises for 20 seconds each he can bend all the way over without a “catch” in the hamstring and he couldn’t feel any tightness at knee lockout with a sitting SLR.
He says he can’t believe it. I ask him if he is curious about it. He says, “ I really don’t give a shit. I was hurting. I’m not now. Who cares?”
I find this is typical of the doctors that I treat.
2 weeks later he calls to say he’s back running 5 – 10 miles without any problems. And he does the rotations and arm raises in standing before running because they loosen him up faster than anything else he has done in the past.
Cool or what?
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College Cheerleader. This is one of the times when the MRI matched the clinical symptoms: HNP on MRI. He has a + SLR, + Well SLR, + (B) Sitting SLR. Interestingly he didn’t have a + Cram maneuver or bowstring. Symptoms have been going on for 3 weeks before getting to me.
He couldn’t bend forward. Extension? Not a problem.
Here comes the humbling stuff or I should say enlightening stuff!
What are we taught about HNPs? Avoid rotation? Avoid flexion? Read on…
First day he gets seated arm raises and standing hip rotations. He feels a bit better. Has some increase in ROM…not great but at least we are going into a positive direction. Yeah…I’m avoiding the rotations.
Third visit: Not doing too well…I add bent knee toe reach and single leg sit to stand. He feels a little better…I’m still not getting what I am used to (dammit!).
Sixth visit: Doing better but not well. I’m used to making bigger and quicker improvements. I decide to monitor his symptoms as we would in any treatment type (McKenzie, etc) and try some other motions…particularly the rotations.
We started with the rotations. Some improvement. No increase in symptoms.
Then we did the rotations with extension and with flexion.
When he did the seated rotations with extensions it “felt better” but there was no change in his active ROM.
He then did the seated rotations with flexion. He stood up then bent forward and touched his toes. The pain was gone. He continued to improve and do well.
What the…
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Male, 50s. Drives a truck for a living. Hurt his back about 3 weeks ago at work. Has been getting PT at a different facility for 2 weeks (“shake and bake”).
Looks to be in an “acute” situation. Barely gets out of the chair when I call his name.
Has right back and leg pain to the foot. Says he isn’t sure why he is seeing me since he has already had PT and it didn’t work…“But I just do what they tell me to do.”
I’m sure many of you have heard that story before or at least something like it.
After my exam I label him a “right lumbar/SI dysfunction”. He can only bend to his upper thighs and has no extension. When he side bends to the left he gets to mid thigh. He can’t do it to the right.
I tell him he’ll move better today.
We start with the rotations. After 2 reps of 20 seconds he stands. He then bends over to his knees. His eyes get wider as he comes up. “I haven’t done that since I got hurt.” He then leans back. Not much change here.
Seated arm raises next…2 reps 20 seconds. He stands and bends to his shins then leans way on back. He then sidebends and is able to touch his knees on both sides.
He is still sore but the soreness kicks in much later in the motion…and it is soreness…not pain.
Next visit a week later: He called to cancel. He went back to work without any symptoms!
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Male, early 50’s. Back problems off and on since 2000. This episode has been going on for about 4 weeks.
Dx: Lumbar strain/sprain (how many time have you seen that one?) MRI: DDD, annular tear. My label: (L) SI/lumbar dysfunction. So the doctor gives him a label, the radiologist gives him a label and he gets one from me.
Movement: Forward bend to the mid thigh and almost no extension. Symptoms: (B) low back pain. No leg symptoms.
The guy says he came because the doctor ordered physical therapy. He said he didn’t think it would help because he had seen a physical therapist a few years ago and nothing happened.
So work cut out for me…
Guess what I show him…yep the twist and the arm raises. After both of them he is able to bend to his shins and leans “pretty far back” or is that “way on back”? (PFB vs WOB).
He has that look in his eyes. “What the heck just happened?”
2nd visit: 6 days later. He says he can’t believe it but the exercises are working. He demonstrates them and I can’t believe he is actually doing them correctly!
He has been able to maintain his ROM. He says he has no pain but the back “feels tight”. I show him the standing hip rotations. 3 reps at 20 seconds…he bend over and touches his toes!
Wicked stuff this TMR!
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OK - I've been lazy for several months. Bill sent these too me and I am just getting around to them in March 2011.
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What’s in store this month: “Treating the Untreatable”
My clients are usually folks that have had symptoms for months or years. Most of them have been seen by several doctors and/or therapists. Kind of a niche that I have accidentally fallen into.
Some of them have been called “Untreatable” or “Maximum Medical Improvement Reached”. Read on…
Female, late 40s, referral from a neurosurgeon. She has a boatload of stuff going on.
C/O neck/upper back/shoulders/arms/hands pain/stiffness/numbness since 2008 and getting worse. Other things: fibromyalgia, MS, Chiari Malformation (had surgery several years ago)…sometimes her hips and feet bother her.
Pretty wicked stuff huh?
She has increased symptoms with sitting, standing, walking, sleeping, driving, using her arms or moving her head.
My label: Right cervical/thoracic dysfunction and Right shoulder impingement.
She could look down about half way. She couldn’t look up. Her rotation was limited at least 50% on each side. Her right shoulder had about 140 of flexion actively. You could really see the pain in her eyes…pain of discomfort, fear, unknowing, apprehension…
It looked like it was going to be a long day for Bill…
Well…seated rotations…got some extension, got some flexion. Interesting…
Seated arm raises…got a little more extension, got a little more flexion…even got a bit more rotation and her arm goes up to about 155.
Her eyes change as the stiffness melts away. I see hope in her eyes. Hope for a better tomorrow.
I stop here. She is smiling.
2nd visit 6 days later: She’s smiling. She’s been able to maintain her motion.
I ask here to show me how she does the rotations. She starts but it’s easy to see that she isn’t testing but just doing. I ask her about it. She says she has been doing the exercises on both sides. She said she read the instructions that said, “Easy side only.” But opted to do both sides anyway. So I tell her to test both sides…she does. The opposite side was now the easy side.
She does them correctly and actually gets more motion. Same with the arm raises.
Now she says that her neck and shoulders feel much better but her hands are the major issue. She says she has pain and tingling then describes it as crumpling up hard construction paper only more intense.
Since I’m on a roll here I have her do the leg raises and the standing hip rotations.
Her neck and shoulders now have full ROM. She says the pain in her hands has decreased and the sharp sensations have gotten dull.
Two more exercises added for her today.
3rd visit: She is still smiling…very cool. Today her major complaint was a spot at the base of the right side of the skull. Her hands were still having symptoms but less intense.
We clean up the exercises a bit. The arm raise helped to decrease the skull pain. I decide to add the single leg sit to stand. She does a set of 10 then a set of 5.
The skull symptoms are gone…the hand symptoms are continuing to decrease.
Sometimes you just gotta ask, “What the hell is going on here?”
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Female, 40s. Very wicked case.
History: MVA summer of 09. Cervical fusion: 1/2010. Surgery did not help. To make matters worse, after surgery she could not lift her arm over 85 degrees of flexion. So now her neck pain is the same as it was prior to surgery plus she now has a shoulder issue.
Other stuff: Lumbar fusion a couple of years ago and still having occasional symptoms and fibromyalgia.
“Wow.” I said in disbelief…that is until I found out who did her surgery. “An aggressive surgeon” he is called. He told her that her “fusion looked great”.
He also told her it might be one or two years before she regains control of her arm.
“Wow.” I said again in disbelief.
She said her neck was stiff. Stiff?! Hell it was immobile!
Her eyes looked like she was sucking a lemon as she tried to turn her head or look up. Looking down was no party either. At least gravity was helping.
Wondering about how her back was working I ask her to bend forward. She gets about ¼ the way down…still sucking on that lemon. She has no extension.
Checking out her shoulder I make a very, very exciting find! She has full passive ROM with minimal guarding.
I go out on a limb…I don’t do this often.
“What if we get your shoulder moving better today?” I ask.
She looks at me like I’m nuts.
I have her do the seated rotations.
40 seconds later I ask her to raise her arm…it goes up. She turns her head to watch her arm rise until it stops at about 155 degrees.
She says, “I don’t believe it.”
“What part?” I ask. “The arm going up or your head turning and watching it.”
She starts chuckling.
I then have her stand to check out her back. She bends over and touches her toes then goes back and has what I would call WOB…Way On Back extension.
The she starts to laugh…better than crying. She says she’s going to stop by the doctor’s office and wave at him.
I stop here. She leaves the office with one exercise.
2nd visit: Her back still has full ROM. She is still happy with how things are after all these months.
So what is left? Well her shoulder and neck still didn’t have full range of motion. She still had some pain.
I added the arm raises, 2 sets 20 seconds. They helped a bit but not much. I then add the standing hip rotations. http://www.youtube.com/watch?v=Mn5T21NmyYg
As she steps away from the wall I ask her to look up. She does. She can see the ceiling. Excited she looks over each shoulder. No lemons today! Like an excited kid at Christmas she raises her arm…all the way up, full ROM.
We now stare at each other in total belief.
3rd visit: She has no pain. Her shoulder is functioning fine. Her back isn’t bothering her. The neck only has a spot (around C7) that is “tight”.
We clean up the exercises a bit…tightness is gone.
Again…sometimes you just gotta ask, “What the hell is going on here?”
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What’s in store this month: RN w/“chronic spine pain”, post surgical spine, post hysterectomy groin pain
Female, mid 30s. RN at a nursing facility.
Issues: 1. (B) Neck pain and tingling in the hands 2. (B) Low back pain
Pain Level: 8/10
Start of symptoms: Over a year ago
How: No known injury.
Increased symptoms with sitting, driving, standing, bending, dressing. Decreased sleep.
1stvisit: She could bend to her upper thighs and could extend a little, both of which increased her symptoms. Her neck appeared to have about half the ROM she should have in extension and rotation (to both sides)…Bottom line…Stiff as a Board!
No seated rotations today. I’m not sure why. I just get this feeling…“energy” perhaps?? So I did start her off with the seated arm raises. Afterwards she says she can “move easier”. Her ROM stayed about the same but the “quality” of her motion looked smoother. But I can’t document that dammit!! Well I guess I could, but this is just not good enough!!
Next standing hip rotations…2 sets @ 15 seconds later: OMG! She touches her shins and leans WOB!! Her neck motion is normal!
Home program of 2 exercises: Arm raises and hip rotations!!
2ndvisit 10 days later: Says she has no pain but occasional tightness. Still has a little bit of the tingling but not as bad. She can now has “touch the floor flexion” as well as full motion in the neck! We clean up the exercises a bit and she is now on her own! Not bad after hurting for over a year!
Female, mid 60s. Started having (B) back and leg symptoms in February. Had to walk with a cane for a while. Had surgery for a cyst resection in the lumbar spine mid March. We get her about 6 weeks post op. Works in an office but not back at work yet.
She has been doing a “walking program” but nothing else. She still has back pain/stiffness but no leg pain like prior to the surgery. Difficulty with sitting, driving, getting in/out of her car/chair.
She is very stiff. She can bend to her upper thighs and has very little extension.
I show her the arm raises. After 3 reps/15 second holds she can bend to her mid thighs and get some more extension. Not great stuff so we press on.
Next…the rotations…No! I think not. Going right to the hip rotations. Why? I’m thinking that I am getting more “bang for the buck”. This is usually more difficult for folks. She can do 3 sets of 10 second holds. Result: She is able to bend to her shins and leans WOB.
So she has 2 exercises to do at home.
2ndvisit 2 days later: She says she is better than the first day but hasn’t done her exercises as often as she should have. (I tell her that means she is “normal”.)
Today she says she is really stiff but not as bad as day one. Today she can bend to her knees. So she is better but not as good as she was when she left the first day. She has some extension but not as good as it was.
We start the exercises. She starts with the arm raises. She doesn’t test the sides. Says she has been doing them on both side when she does get around doing them.
So she does the easy side of the arm raises. Now she can get to her shins again.
Next the hip rotations…afterwards she bends over and touches her toes! She comes up and says she hasn’t done that since January!
I reiterate her doing the exercises only on the easy side.
3rdvisit: Is back at work half days. No pain. Walking 2-3 miles now.
Female, late 40s. Has had right groin pain ever since she had a hysterectomy several months ago. The also has low back pain, right hip stiffness and occasional foot numbness. Dx: Adductor Tear. Not really sure how the doctor thought that one.
My label: Lumbar/SI dysfunction
1stvisit: Primary issue is the groin pain with walking, getting in/out of a car, stairs, crossing legs. Secondary issue is back pain.
She can bend to her mid thighs. She has some extension but not a lot. Her right hip flexion is limited because of pain.
We go through the arm raises and seated rotations. She is able to bend to her knees and gains a bit in extension. I try the seated leg raises. She can barely do it and gets big time cramps in her upper thighs. So we just to a seated hip flex. After 3 reps she is able to have hip flexion on the involved side. She still couldn’t cross her leg or go into external rotation well.
But she’s happy. The best she has felt or moved in months.
2ndvisit: Reports she is doing better. Still has all the symptoms but less intense. We go through the exercises…clean them up a bit. Add the standing hip rotations and boom she is able to touch her ankles and the groin pain drops.
3rdvisit: Says she is still progressing. Had to clean up the standing hip rotations a bit.
4thvisit: Says this is the best she has been so far. No problems with hip flexion, getting in/out of her car, stairs, dressing or walking. She can almost cross her legs. At this time it is the only issue she has. She says she feels just a little “glitch” as she picks up her leg.
Since she was already doing the seated hip flexion as an exercise I try her in a different position: Supine. I give her resistance to external rotation, to her easy side of course, since that motion has to happen for her to cross her legs.
Didn’t work. Crap. I know we didn’t do the seated leg raises because of how severely she cramped up. I ask her to try it again…she is able to. Get this…her easy side was the side of the issue. Gotta go with what I was taught.
2 reps and 30 seconds later…she crosses her legs…then does it again…and again.
“The pain is gone.”
Every day is great to be alive…some days are just a bit better!
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What’s in store this month: Partial Achilles tear, radicular symptoms, necks
I’m always trying to find some type of correlation with a TMR movement to an issue. More so with backs and necks since this is and has been my specialty area since ’93.
The hip rotations, http://www.youtube.com/watch?v=Mn5T21NmyYg, specifically in external rotation have worked well to regain motion in extension/flexion of the lumbar spine. Interestingly it tends to help necks as well.
Female, Early 30s, RN. Has been having (B) neck and back pain for over a year. No reproducible neuro tension/compression signs.
Increased symptoms with sitting, standing, walking, looking up or to the left, or bending forward. Her ROM overall didn’t look too bad except with lumbar flexion. She could only get to her upper thighs.
My label: Left lumbar/SI/cervical dysfunction.
I start as I always do…with the seated rotations. While she did improve with rotation to the other side she didn’t get much of anything else (man I hate that!).
On with the arm raises. After 3 sets of 15 seconds…she “sees the light”. She can bend to her lower thighs.
So on to the Standing hip rotations http://www.youtube.com/watch?v=Mn5T21NmyYg.
She did 3 sets of 15 seconds. She stepped away from the wall and bent over to her lower shins. On the way back up she says, “ Wow!”. So I ask her to look up…like I knew what would happen. And it did! Much more extension and the same with rotation. So verry veerry cool!!
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Male, mid 60s. Work: Sales. Woke up one morning about 6 weeks ago and hit the floor. His heel hurt. No injury. Had an MRI and showed a “partial Achilles tear”. He was put in a boot for 4 weeks. After he got out of the boot he felt a little better but not much. The doc put him in some type of restrictive stocking then the dorsum of his foot got worse than the heel.
So he limps in today. No ligamentous instability. Extremely tender on the top of his foot and heel. A bit decreased in ROM/strength ‘cause of pain.
So hey whacha gonna do Bill? Arm raises? Rotations? Well I’ll get around to that.
I start him off with some kind of ankle twist that was in the TMR 2 book.
He does it on the easy side, 3 reps at 15 seconds and walks away and says it feels better.
So next I try standing heel raises just on the easy side. No change.
Now I’m 1 for 1.
Next the seated rotations: Bingo! He gets up and has less pain in the heel. The top of the foot is the same. He likes this because he gets more trunk rotation. He says he is going to use it for golf. I tell him we do for our golf program.
Next the arm raises: Bigger Bingo! He walks with even less pain in the heel. The top of the foot is a little better.
Next bent knee toe reach: Biggest Bingo! Says he has no heel pain…which is the main reason he is here. And the top of the foot is better. Still has a limp but not as bad. Best he has been feeling in 6 weeks.
Home program: Arm raises and bent knee toe reaches. Seated rotations: optional.
2ndvisit 2 days later: No limp! Heel pain gone!
A week later he stopped by to say “Thanks” and that he hoped he would never see me again!
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Male, late 30s, teacher. Back patient. Original injury was golf in 2006. Had discectomy in 2007. He did better but never got totally well. Never returned to golf but did get back in the gym.
His present problem started about 6 months ago. Not sure what he did but the symptoms got worse. (B) Low back/butt/leg pain. Right leg pain to the foot. Left leg pain to the thigh.
Can bend to his knees but can’t extend. When he does extend it reproduces his right leg pain all the way down to the foot…every single time. OK? So I think most of us have a “clear” picture of what is going on now.
Well after doing TMR for a few years now (wow can’t believe its been that long) I have found some things that tend to work for the majority of what walks into my rented building…maybe how McKenzie got going. Anyway the seated rotations and arm raises work the majority of the time.
So now I’ve got this guy here with reproducible stuff. What I have found is that the arm raises will get most people more extension and flexion (obviously that’s why I use them!). So I skip the rotations and go right for the arm raises. 3 sets of 15 seconds. He can now bend to his shins. Cool. I ask him to lean back. He looks squeamish. But he goes along with it and can actually lean backwards a bit. He got the posterior thigh pain but not the lower leg pain. Very Cool.
Next. I have him do the standing hip external rotations http://www.youtube.com/watch?v=Mn5T21NmyYg
2 sets of 15 seconds. He bends over and hits his ankles. Cool again. Then he leans back…I mean WOB (way on back). No Freaking Leg Symptoms!
Mega Cool!
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Male, mid 50s, truck driver. Has right low back and leg pain to the right foot. Symptoms have been going on for about a month and are constant.
He can bend to his knees but can’t extend cause it increases the pain to his foot. Sound familiar?
Arm raises first bends to his shins and able to lean back a little bit.
Hip rotations next. Now he touches his toes and leans WOB…without symptoms.
His reaction: “Unbelievable!”
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Female, early 50s. Neck/upper back pain, right > left. Has been going on for 10 years after falling. Symptoms are intermittent but daily.
Her right sided rotations is about half of her left but “both feel tight”. She hardly has any extension but it doesn’t hurt. It does hurt to look down.
I tell her we are going to do an “indirect” exercise.
I show her how to do the hip rotations. While doing her first rep she asks, “What does this have to do with my neck?” I just say, “It’s all connected. Keep pulling the foot up.”
After 3 reps of 15 seconds I tell her to step away from the wall and “look up and over your shoulders”. She says, “Wow I don’t believe it. What’s going on? How did that work? I should have come here sooner!”
She leaves with 2 exercises the hip rotations and cervical ROM…I mean we are “treating her neck” aren’t we??
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Female early 50’s. (B) Neck/upper trap/arm symptoms for almost 2 years. No known injury. Has been getting worse the past couple of weeks. Work: substitute teaches on occasion. No reproducible neuro tension/compression signs. No strength deficits. Some limitations with CROM. Exhibits (L) shoulder “impingement”.
I went out on a limb with this one. I told her that her shoulder shouldn’t bother her when we got done. (Why the heck did I do that?!)
Started with the arm raises…simply because it was the direct opposite movement. So after 3 reps @ 15 seconds she was able to raise her (L) arm “easier”. She was amazed to say the least…which is very cool. She kept wanting to know why it felt so much better after one exercise…and how did the right side do anything for the left. And why it still bothered her at end range. I told her I would answer her after we get rid of the symptoms.
Soooooooooo…did I do the rotations? Noooooo…did I do leg raises? Nooooo…I had her do single leg sit to stand. I didn’t think she could handle 2 sets of 12 so we did one set of 10…rested about 20 seconds…then another set of 5.
So what happened? She raised her left arm and said all the symptoms were gone. She then moved her head in all directions…no symptoms. At this point she said she didn’t care why it worked anymore but wanted to know how to keep it away!
Heck sometimes we just get lucky…or maybe just maybe I know what I’m doing...
Female mid 40s. Has had some mid-sternal (best location description I have) pain for about 2 weeks. No injury noted. Bothers her when she coughs, rolls over in bed and sometimes putting on her shirt. Wanted to know if she had to take her shirt off (NO.) XR: neg.
Short story, shorter…one exercise…seated rotations. Pain gone. She could cough and roll around on the plinths…and I didn’t have her take off her shirt…
2nd visit: Feeling much better. Could sleep better, roll in bed, put on her shirt. Cleaned up the exercise a bit…that’s it!
Male, Mid 50’s. Saw him about 2 years ago for his back. He did well. Matter of fact he said that what we did 2 years ago “changed his life”. Wow. Those are the kind of things you really like hearing (got to watch out for the head swell though).
So he’s back…for his back…but this time it’s not as bad. He has (B) LBP, no reproducible neuro tension/compression signs. My label: (L) lumbar/SI dysfunction. He could bend to his knees and just had a little ext. Which actually was better than a couple of years ago!
Back then I just did the manual stuff and some exercises and apparently “changed his life”. I could have done the same thing again this time…which would work…but I remembered the little old lady from a couple of months ago (the one that I didn’t try TMR because I didn’t think she could handle it). So I tell him I learned a few things in the past couple of years and maybe I could show him something else that would continue to change his life…so…
Seated rotations: 3 reps 15 second holds…he stands and is able to touch his shins. His extension was about the same.
Seated arm raises: 3 reps 15 second holds…he stands…bends over…touches his toes! He then leans WOB (way on back)!
Big surprised look on his face…priceless! He said he wondered what I might be able to show him in 2 more years…
Male late 20’s. Looked to be in acute pain but he says this is how it’s been for years. He says he just keeps on going. Has been hurting for about 6 years after he fell out of a 4 wheeler. XR: negative. Had some chiro treatments w/o help. Got to me because he changed family physicians. He said he change because his other doctor only offered him more pills.
Dude could hardly move. Could bend to his upper thighs…couldn’t lean back. He said this was pretty typical. Some days were better but not much. Wasn’t doing anything for fitness but did “try to stretch” sometimes. Also is a fan of the Wii Yoga thing.
No reproducible neuro tension/compression signs. My label: Left lumbar/SI dysfunction. This was another case I was tempted to just do the manual stuff…since I knew it would work…but I decided to stick to the TMR “guns”!
Yep you know it…seated rotations…got him to bend to his knees…got a little extension. And of course the next exercise was the seated arm raises…bent over and touched the top of his ankles…then leaned WOB (way on back). His wife’s eye got real big at this point! She couldn’t believe it…neither could he!
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Various diagnoses this go round…lumbar stenosis, disc herniation, prior fusion, lumbar spondylosis, lateral shift…lots of back stuff!
Male, early 60s. Diagnosis: lumbar stenosis, lumbar disc herniation. My label: Right lumbar/SI dysfunction. Says he is very stiff with bending forward or backward. Says his back doesn’t hurt much but is really concerned with his leg being numb from the hip to the toes. This has been going on since Thanksgiving and this is mid December. No injury. He is retired…
He can touch his mid thighs. No reproducible neuro tension/compression signs. Does have some weak ant tibs…say a 3-/5…has some problems with heel walking.
So you talk this case out to yourself…not much pain…does have “stiffness”…his major concern is the numbness. Personally I never know if I can ever help the “numbness” but I do know I can help the “stiffness”!
So yes we do the rotation and the arm raises. Afterwards he can touch just below his knees. He sees and feels a change. That’s enough for me for now.
2nd visit: You never know about these cases. He comes in looking happy. He is able to touch his mid shins now. He say he has no back issues stiffness or otherwise. The leg is doing fine. The only thing he has now is a little tingling in the toes…not too shabby. We review the exercises…call it a day…oh and then he shows me that he can heel walk without any difficulty.
Very cool, indeed!
Male, early 60s. Has had some back issues for years. Finally had a one level fusion about 8 years ago. His back has only bothered him 3 times since the surgery and only for a few days. This current episode is different. It has been going on for about a month. Has an office job and travels a lot by car.
No injury noted. Says he was really active the last weekend of November…getting firewood cut and stacked. The back just “went out on” him while he was sitting at his desk 2 days later.
He has a “mild” + SLR at about 45, “mild” sitting SLR…so maybe…just maybe he’s got a little nerve irritation along with a little lumbar/SI dysfunction. When I ask him to bend forward he laughs. Says there is no way…but he is able to get to his upper thighs. Has some extension but not much.
Everyone knows by now that I’ll start with the rotations then the arm raises…why change now since this works? After the rotations he can touch his mid thighs…after the arm raises he can touch his mid shins and get a lot of extension.
He can’t believe it…says so… I believe it…see it every day!
2nd visit: Says his symptoms are almost all gone. Negative SLR!
Early 40s, female, bus driver. Has had low back issues since the ‘90s. This episode started about 3 – 4 months ago. (B) LBP, right > left. Got an epidural several weeks ago that helped a little. Also has seen a chiropractor several times but no lasting results. No recent injuries.
Docs’ diagnosis: lumbar spondylosis. She says she has “scoliosis, several bone spurs and bulging discs”. My label: Right SI/lumbar/thoracic dysfunction.
She can bend to her upper thighs and has very little extension.
So she gets my BIG TWO exercises. She can move a little better. Not the big “miracles” that I like to get…but I’ll see her again in a few days.
2nd visit: She says, “Yesterday and today I haven’t had pain.” Not bad for 2 little, bitty exercises over the course of a week. Oh yeah…she tend bends over and touches her toes. Then leans way on back. The next question she has is “When can I get back to the body pump classes?”
Anytime…
Female, mid 40s. Works 12 hour shifts as an RN. (B) low back pain, left hip and leg pain to the knee. Lateral shift to the left. She says it all started about a week ago…gradually. She can’t remember any injury…but she did fall off a horse about 3 weeks ago. Contributing factor? Maybe…maybe not. Can only bend to her upper thighs and has no extension.
So after the big 2 exercises. She is able to bend to her knees and has a little extension. Not a huge improvement to me. She seems to be happy though and I am here for her…not me. I like to err in doing “too little”. If you do too little you can always add more later. If you do too much you kinda end up paying for it!
2nd visit: Doing better. She says she is straighter. I agree. Her leg symptoms are gone. She can bend to her shins now. I proceed with more movements, specifically seated leg raises and single leg sit to stand. No big changes in ROM but she says she “feels better”.
3rd visit: Says she’s doing great…has no pain. Can bend over and touch her fingers to the floor. Has more extension. Says she can feel it a little bit leaning backwards but not much. She’s happy and wants to start riding again! No lateral shift!
Very cool…and in a week and a half!
OK…sometimes we make mistakes. Last week I had a woman in her 80’s here to see me. Pain for years. Seemed frail. Used a cane. She’s had increased pain after a bad bout of COPD about 3 months ago.
Has (B) LB/lateral hip pain…constantly. My label: right lumbar/SI dysfunction. My “mistake”…I “felt sorry” for her…so I did the manual stuff and not the TMR stuff. I just didn’t want to go through the exercises with her. I didn’t think she could handle them even though we all know I would only start with the arm raises and twists.
Results…she felt a little better when she left from the manual stuff…which I knew she would.
2nd visit: She says she is doing a little better overall. But still a bit stiff on the right. Today I thought maybe…just maybe she could do some of the exercises. Interestingly enough when she did a seated hip flexion movement it was tight. I had her do the seated rotations and the arm raises. BOOM. No problem with the hip flexion. She stood up bent over and backwards more freely and walked across the room “easier” and without the cane!
Moral: If I really, really “felt sorry” for her…I should have given her the best advice/treatment I have to offer! Dammit!
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Check out Bill's Exercise Blog at http://jonesercise.wordpress.com/ and wow they do some amazing exercises.
Here are some cases from this month that may get to some PTs…how about a few seniors, a couple of workers comp case, a nurse and a physician?
Female mid 50s. LPN that works 12 hours shifts. Hurt back about 4 months ago. Slipped on water at work but didn’t hit the floor. Has seen a chiropractor in the past w/o help. Has been on meds w/o help. Was on bed rest for a week with minimal help. Symptoms are getting worse. (B) Low back, hip, leg pain with some tingling, numbness. Has occasional urinary incontinence. In tears. Actually brought in some FMLA papers for me to look at…she’s afraid she’ll loose her job.
No reproducible neuro tension/compression signs. Can touch the front of her hips when she tries to bend forward but can’t bend backwards…actually can’t even stand erect. (B) hip flex 3-/5…probably because of pain. After my eval I give her my label of: Left lumbar/SI dysfunction.
So I could do what I used to do…manual therapy wise…but hey do I really want to touch a crying woman only to watch her mascara drip dark Alice Cooper lines across her cheeks? Well No I don’t!
You get the picture by now…I have her do the twists and the arm raises…whining the whole time…not me, her. No big miracles the first day. So I have her squeezed into my schedule the very next day.
Next day: Not sure what I’ll see when I go to the reception area. I open the door…No Tears! She gets out of the chair. Small smile. She shows me the exercises. Does them OK. I add the seated leg raises…and the standing hip rotations http://www.youtube.com/watch?v=Mn5T21NmyYg.
She still hurts. She isn’t crying. Oh and she can bend to her knees and actually has some extension today.
I set her up to see me again in 3 days…she cancels.
Mmmmm…what does this mean…well read on…
3rd visit: It’s been 8 days since she’s been here. I have no idea what to expect. I open the door…she gets up…broad smile and she’s moving fluidly.
She says she can’t believe how much better she is after all these months and in only 10 days. She still has some symptoms on the left side of the back and anterior thigh. Not painful but stiff feeling sometimes. No incontinence episodes.
She sits down and immediately starts her rotations then her arm raises. Then she bends over and touches her shins and leans WOB (way on back)! She continues to knock out the leg raises and standing hip rotations…
Next she asks if we ever hire LPNs. No is my reply…she says, “That’s too bad. I wish I could work with something I believe in.”
If that isn’t powerful I don’t know what is…
Male, late 50s. Has had some pain behind his knee for about 2 years. He has been working out regularly and his trainer stretched the stew out of the area with no change… good or bad. The pain got worse during a hunting trip about month ago. It was so bad he had to be wheeled around the airport in a wheel chair. His job: physician (ob/gyn).
Has seen an orthopod that sent him to therapy (not to me) for hamstring tendonitis. Got bunch of different modalities and exercises w/o change.
MRI: spondylosis with central L45 bulge. No nerve tension/compression signs. Sent to me via neurosurgeon.
His issue today: Pain behind his knee. Interesting is that he can only reproduce the symptoms with seated hip/knee flexion (and walking after awhile). Apparently this movement has been bugging him for a couple of years.
After my exam I label him with a “left lumbar/SI dysfunction”.
So my choices:
1. Loosen his back up which would have an effect…eventually….Or
2. Start with TMR…and have to try and explain to the doc “how it works”.
And what do I start with?
Well I should have started with the exact opposite motion but I’ve been so caught up with my pattern of seated rotations/arm raises. Heck I’m into the second set of rotations before I realize it.
But guess what happened? After 2 reps of 20 seconds…he raises his knee…gets that look on his face that asks “What just happened? It feels better.” It wasn’t gone so I tell him to do it again and hold it for about 30 – 40 seconds. He does…Pain almost gone. He can’t believe it. Hell I had my doubts too but he now has a home program of one exercise.
Occasionally I wonder what someone may think of the treatment I provide. So in this case I wonder what the doctor is thinking? “That dude only gave me one exercise…” or “That dude only gave me one exercise…and it worked. What’s up with that?”
2nd visit: He comes in…has a seat…Says he’s doing better. The symptoms are still there but not as bad. I have him do his home program again. Big deal… he’ll be done in 40 seconds. He is able to “modulate” his symptoms. I have him do another rep at 30 seconds. He says the symptoms have decreased again but “seems like it is leveling off”. So I have him do single leg sit to stand. He say it helped some but not much. So I have him do what I should have before: Stick with what works till you stop getting results…i.e. no positive change after 3 data points!! So he does the seated rotations, 2 reps with end range emphasis. Next he lifts his knee…big smile on his face and says “This is the best it’s felt in 2 years.” Not bad for a couple of exercises over the past 3 days.
3rd visit: Says he had a little more leg pain for one afternoon but the exercises helped to “chase it away”. Reports this is still the best he’s been in 2 years. Didn’t do as many exercises over the weekend cause he was caught up in some tailgating at a ball game. Likes the seated rotations.
4th visit: Says he is down to about a 2/10 from an 8/10 regularly. Again didn’t do much of the exercises over the weekend. He is able to touch his toes now and no problems with extension. I decide to show him the hip rotations…
For the first time in 2 years his symptoms are totally gone…guess what new exercise he has for his home program??
Female, 70. Back problems since 2007. Had a fusion in 2008 which helped only for a few months…had an epidural 3/09 that helped for a few weeks.
Today…limping. Difficulty with sit to stand, walking, standing, bending, reaching, dressing, driving, can’t walk in stores, hurts to bear weight on right w/o increased symptoms. (B) low back pain and leg pain to the knees, right > left. My label: Right lumbar/SI dysfunction.
First day noticed she is very negative. Didn’t think anything would help. How would PT help where surgery, meds and injections didn’t?
2 exercises…yep seated rotation and arm raises. She’s amazed and beaming. She can now bear weight and walk w/o a limp.
2nd visit: Doing better overall. Still walking better…not farther yet but better. Doing the exercises on both sides instead of just on the easy side. We change that. Give her some pointers again and add seated leg raises.
3rd visit: Says her left side is fine now. Still having some symptoms on the right side but not as much. Says she vacuumed for the first time in months…heck I would have let that go a little longer! She said she was trying to “fix” one of her relatives by phone because they had the same symptoms. Today we clean up a few things. The first day she had problems getting a sock on her right foot. Today she can do it but it’s still just a little uncomfortable. So I have her do the same motion on the left side…that is seated hip flexion with external rotation…she cranks out 3 reps at about 10 seconds…retests the right side and the “tightness” was gone. And she just got another exercise
So after only 3 visits and in pretty bad pain since 2007 her doctor says he’s releasing her because she’s doing so well…it’s only been 13 days since I met her.
Male, late 40s. Work Comp. Hurt on the job lifting a bed. (B) LBP, left > right. Wakes him up at night. Worse in the mornings. Has been going on for about 2 weeks. Sitting and sit to stand are bad. Reports he does better with movement.
Has no extension and can bend to his mid thighs. No reproducible neuro tension/compression signs. My label: left lumbar/SI dysfunction
Got him going with the seated rotations and the seated arm raises. Afterwards could bend to his knees and had a little extension…no miracles here.
2nd visit: Doing better than the first visit. Review his exercises. Although his subjective complaints were lower his motion was about the same as when he left 2 days ago. So I get him going on the seated leg raises and the single leg sit to stand. He was then able to bend to his shins and had more extension.
3rd visit: Says he’s doing even better but got really sore from the single leg sit to stand and the leg raises. He said he worked the soreness out. Wonder if he realized he may have been working the soreness out with TMR? It’s been 7 days since I met him. Today he says he “doesn’t really notice it”.
4th visit: Says he’s pretty much doing everything he is supposed to do at work. Was able to go deer hunting over the weekend. On Halloween was able to take care of his 5 grand children. Has full ROM. Says every now and then he feels a “nag” as a reminder that he needs to be aware of his body mechanics.
80 y/o with back and leg issues for 10 years but getting worse. Only bothers him with standing and walking. Standing is the worst. He lasts only about 5-10 minutes w/o getting symptoms in his left low back and leg.
Obviously has lumbar stenosis. Also w/my exam I find left SI/lumbar dysfunction. Can bend to his knees. Has only a little bit of extension. Sidebending looks stiff and almost to mid lateral thigh. The good thing is he has no reproducible leg symptoms…that is unless he stands or walks between 5 – 10 minutes.
2 exercises for this senior today. Guess what they were? Yep Seated rotations and seated arm raises. Guess what happened? Yep he regained more motion…could bend to his shins and had pretty good extension. His side bending increased to where he could get to the lateral knee.
2nd visit: First thing he says is “I’m doing better.” He says he hasn’t tested the walking yet but he notices he can stand at least 15 – 20 minutes now without the symptoms. Not bad in only 5 days. Today we clean up the exercises. He wasn’t holding as long as instructed. Afterwards got a little more flexion. We added the seated leg raises and he could then bend to his ankles.
3rd visit: Doing even better. Doing the exercises well. Says that he was walking for over an hour the other day and didn’t notice the leg symptoms at all. He can touch his toes now.
Yeah…I am totally amazed at this one!! He’s happy and so am I!
Male mid 40s. Dx: DDD. Low back/buttock pain off and on for years. Has been getting worse the past 2 months. Sent to me via neuro surgeon.
No reproducible neuro tension/compression signs. Works in office and sits a lot. My label: left lumbar/SI dysfunction. Could only bend to his knees and could bend backwards some but it hurt.
2 exercises: seated rotations and seated arm raises. Could bend to the shins and could lean back w/o any pain or tightness.
2nd visit: says he is doing well. How well I ask? Oh about 90 – 95% well. (Heck if it was me I would have called and said thank you very much see ya later. Nicer guy than me though.)
He does the exercises relatively well and actually is now running again about 2 – 3 miles a day.
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Let’s see if this little intro makes you want to read the whole thing this month:
A disabled person, a physician, a pregnant girl, an ex athlete, a couple of them post op. Intriguing? Extreme end range? End range with resistance? It’s all here this month!
Now this is a very cool case…an example of someone that was probably overly medicated and overly tested from July till Sept. However she was treated and back to work in little to no discomfort in 10 days.
Female, early 30’s. Fell down, landed on her rear in July 09.
Stuff going on since July: (B) LBP, (L) ant thigh pain, (B) buttock numbness, limping into the office, constant symptoms, increased symptoms with sitting, sit to stand, can’t sleep. Can only bend hands to the front of her hips and no extension. No reproducible neuro tension/compression signs
Interventions: Steroid injections, oral meds of various types, off work, neuro surgeon consult, pain control doc consult. Bottom line: No relief.
Tests: XR: Negative
MRI: Minimal DDD L45, no evidence of nerve impingement
CT: Evidence suggesting SI dislocation
BoneScan: Negative
So we know the DDD didn’t start with the fall. We also know that the CT showing “evidence suggesting SI dislocation” is probably just that…a “suggestion” certainly not evidence…especially since the bone scan was negative. And hell dislocating an SI joint would create a boatload of traumatic inflammation!
My analysis/label: “Right lumbar/SI” dysfunction.
My treatment plan: Fix patient.
Initial visit intervention:
1. Seated rotations: Afterwards able to bend to her knees but no change with extension.
2. Seated arm raises: Afterwards able to bend to her shins and extends pretty far back there.
That’s it for the first day…she has more ROM, less pain…oh yeah…she has no limp.
She tells me these movements are “so simple and they work”. “I feel like I should know these already.” Why? Her occupation: Physician…(and out of network).
2nd visit 6 days later:
I open the door to the reception area. She smiles. Good sign. She asks me to turn around because she wants to see my “wings”. Says that I am an angel (obviously doesn’t know me well).
Reports being about “65% better”. She has no limp. She is back at work. I go over the exercises again…clean them up. Add the single leg sit to stand. She now can touch the top of her feet. Extension looks good.
3rd visit:
Says she is doing much better now. Still walking normally. She does her exercises: seated rotations, seated arm raises, and single leg sit to stand. I clean it up a bit but she is really doing well.
Afterwards no symptoms…wants to start going “back to the gym”…fine by me.
Male, late 40’s, about 2 months out from anterior lumbar arthroplasty, “new disc”. Had been having “bad pain for about 8 months”. Had gone through a variety of injections w/o relief. Says he had physical therapy (not here though!) without help. He’s a bit apprehensive about therapy now since “it didn’t help before surgery”.
Anyway he was doing better after the surgery but while driving a few days ago hit a speed bump. Says he felt jarred and the symptoms shot back up again.
No reproducible neuro tension/compression signs. Strength normal. Increased symptoms with sitting, standing, sit to stand, bending forward/backward and he can’t sleep. He can bend to his upper thighs and has just a little extension.
My label: “Right lumbar/SI dysfunction”.
Start him off with the rotations. He can now bend to his knees. Still not much extension.
Next the arm raises. He now bends to his shins and extends very smoothly and very little discomfort.
2nd visit: Says he is doing much better. Says he has no problems with the exercises. Yeah right! That’s what they all say! He does them…actually fairly well! My bad (can’t believe I actually wrote that!). I clean them up a bit. I show him the End range with resistance with the rotations…he stands up and bends over…touches his ankles. He’s impressed. Me…just another day at the office!
3rd visit: Says he’s still better but feels “a little stove up”…which in the south means stiff as a board! He says he’s had to do more sitting at work. The beginning of therapy he can still touch his ankles but upon standing extension he doesn’t go back as far.
I have him do the rotations with the end range emphasis…he gets more “comfortable motion” but still feels “it” with extension. So hey…lets break out the seated leg raises…he does 2 sets of 10 second holds…because he can’t do it very well. He stands up and then is able to touch the top of the feet at the arches. He bends back farther but still gets the little squint in his eye…kinda like sucking on a lemon. So I have him do the single leg sit to stand. He does one set of 10 followed by a set of 6 (yeah, he’s not in great shape). He then stands and bend forward…touches his toes. Then he leans back without a problem…and his eyes do not flicker! He’s all betta!
Male, early 40s, on disability. Lives about 3 hours from me. I have seen him about 7 or 8 times for his back over the past 14 years. He is usually a “quick” manual therapy fix.
Multiple surgeries: (L) hip twice, (R) hip, (B) shoulders, Lumbar surg, (B) knees, (R) ankle. HTN, DM. Most recent surg is the right hip. Had an intertrochanteric osteotomy in June. Not a common surg…some surgeons aren’t good enough to do it…course they wouldn’t admit that…but this guys’ surgeon is good.
Was on crutches in the beginning because of the surgery protocol. Now on crutches because of pain. His doc says he can go without them when ever he wants. Has been having PT close to his home. He says he is in pain every time he goes and it usually takes him 2 days to get over it. (Man I just don’t get it…why are so many people being put through more pain!)
Symptoms: Right Low back/lateral hip/groin/knee and ant thigh pain/stiffness. Symptoms increase with sitting, sit to stand, standing, walking, bed mobility…you named it and it hurts! No reproducible neuro tension/compression signs. Flexion: bends hands to upper thighs. Extends a little past straight up. My label: “right lumbar/SI dysfunction”.
So yeah…again I start him with the seated rotations. He can then bend to his mid thighs. I do it again but this time I have him use the extreme endrange. He can now get to his knees. Now all of this is pretty cool…his wife is watching an is impressed. The patient has less pain now. Anyway we do the seated rotations again but with an isometric overpressure called End range with resistance. He stands up and touches his toes! He asks his wife, “Did you see that?!” She smiles and nods. He says he wants to make sure cause she’s doing that you him at home.
2nd visit: Can still touch his toes but still some problems with extension. I have him do the arm raises. It helps some…but not enough for me. So I have him do the standing hip rotations. He then has full extention w/o symptoms. We talk about what else he does in PT. One thing that bothers him a lot is a unilateral bridge. He can’t do it. The therapist he goes to usually lifts the involved side and has the patient lower it…eccentric contraction for all you folks just wanting to read some jargon…So we simply have him do 2 sets of 10 on the easy leg. He then tries the involved leg…no problem, knocks out 5 reps and he had never been able to after surgery.
He can now walk on one crutch…less pain…more mobility.
Male, early 30s. Had been an athlete all the time…football, softball, baseball. Actually played arena football for a few years. Teaches now. Has had low back and leg pain since May 09. Had discectomy mid summer. No change in symptoms.
Flexion to his thighs. Extension: just a little bit. Positive Sit SLR and supine SLR at 40. Also “right lumbar/SI dysfunction”.
I tell him he may touch his toes today (sometimes you just get a feel for this stuff). He says he hasn’t done that in years.
In a nutshell…does the rotations bend to his shins…not much change in his extension.
Does the arm raises…his fingertips are ¼ of an inch off his toes (hell I guessed pretty close to an intertester reliability of goniometric measurements!), normal extension. Now get this…a negative sitting SLR and his supine SLR is a “mild” + at 55.
2nd visit: Says he’s doing much better. Does the exercises very well…may be the coach in him or maybe I’m finally getting better at giving directions! Says he wants to get back in the gym…oh yeah…he’s touching his toes now and no SLR symtoms.
Here’s the thing with pregnant women…many have back pain…they go to the doctor and he/she says, “Well you’re pregnant.” Which I think is pure BS…not the pregnancy thing but having a doctor blow it off when back pain can be treated easily, safely and effectively.
I’ve seen many a pregnant women (in the clinic of course) and have treated them effectively with manual therapy. But now I have another choice…TMR.
Human being, early 30s, pregnant…oh yeah…female. SI and butt pain for a week. Can’t sit. Once she does sit, can’t get up. Hard to move in bed. Can’t bend forward or backward. Limps. Can’t put much weight on the right leg.
No reproducible neuro tension/compression signs. Can only bend to her upper thighs but can’t extend.
In a nutshell… she does the rotations, arm raises…touches her toes and leans way on back…eyes get big…is amazed…and has less pain. Now she still does have pain but it is less intense and she has to move farther to feel it. She’s happy. I’m happy.
2nd visit: She’s not so happy (dammit)…well she hasn’t been doing her exercises as prescribed, no heat/ice or WD 40, and she has been over working herself…she is an executive for a nonprofit…long on hours, short on help. We do the exercises again…she a bit better…not great…I have her come back the very next day.
3rd visit: Now she’s better. She walks without a limp. She can bear weight on the right. She can bend hands to her thighs and can extend some. I go through the exercises again…I show her the End range with resistance…she stands and then bends to her knees. Now we are getting someplace.
As a side note: Her dad is a PT and her sister is in PT school.
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Ok - I have to share this story prior to sharing all of Bill's Stories for the month. One of Bill's PT buddies took the course with him a couple years back. His name is Hank. That's him above. Yeah - he looks irked that someone took a picture of him, but really that is the way he always looks. Don't hold it against him - he is a lot of fun to poke fun of and he can give it right back as you will see from his email.
He has struggled and of course at times poo poo'ed the heck out of TMR however here is what happened to him today or maybe it was yesterday. He emailed this to me today (9/16/09).
Alright,
As I was laughing yesterday with this pt. I said if I were my buddy Bill this result would be flashed across the internet within minutes (Look there now Hank - you too are an internet sensation!), but since I was a horrible typist no such chance. Now I come in and my first 2 pts have cxl thus I will labor at this keyboard.
This was grumpy gentleman who came in with L shld impingement. Started him on the samething I’ve done for the last 22yrs, mobility and light strengthening of both the glenhumeral joint and the scapulothorasic joint. Visit 2 a little better, visit 3 reports his R shld is killing him with all the bil. ROM and strengthening. ID’ed hand behind his head as an issue. Taught him TMR elev, twist and leg raise. He immediately resolved any asymmetry and all of his pain with hand behind head. Was to drop all the previous exercises and 2x/day pick an issue and work to out w/ these 3 exercises.
(Now I’m cutting and pasting from my notes 4th visit)
S: The patient is quite pleased. He is able to self modulate his pain with TMR exercises.
O: The patient demonstrates full active range of motion. No pain with palpation. He was slightly limited with internal rotation on the right. Manual muscle test 4/4 external rotation.
TX: Moist heat deferred ,active warmup with a UBE. Then performed PREs of flexion, scaption, tubing, internal and external rotation. We had to stop secondary to increasing pain in his right shoulder and then treated himself with TMR with active elevation isometric end range holds on the left and trunk rotation. He was able to completely eradicate his pain on the right.
A: We will combine the two treatment sessions. Hopefully TMR will knock down his pain and allow us to get more strengthening.
P: Weekly.
Visit 5- yesterday
S: Patient states he has done a good job modulating his pain with his TMR, is not having much problem at all. He is doing his strengthening exercises. He does, however, complain of reaching out of his car window for the drive-up teller canister and he believes this is the fulcrum that causes him acute pain.
O: Replicated this motion with acute pain. Described 80% dysfunction as opposed to no pain on the uninvolved side.
TX: Patient self-treated with two 20 second isometric holds with active elevation and trunk rotation to the good side with immediate and complete resolution of his shoulder pain. Patient then was instructed in FAB5 program of TMR including single leg sit-stand and single leg reach. Issued flow sheet outlining TMR program and reviewed issues.
A: Encouraged to continue with his active strengthening though use TMR as he needs to for pain. Also suggested he balance out any asymmetries of the FAB5 every morning to see if he can alleviate some of his discomfort.
P: Weekly.
This is my kind of therapy, I’m sitting with my back away from him working on the computer, and after 80 sec. of isometric holds he completely eliminates his dysfunction. I told him I have been cheating him by not showing him the full program which I then did. He had told the MD that his other shld had starting hurting with the conventional exercises though Hank was doing some Voodoo on him that was really working. He was just giddy. He sought out his daughter who was in the clinic being treated by my very skeptical colleague and thus bragged on his parlor tricks . My colleague is bemused as to what and how and we don’t really care except with the result.
Personally, have generally gotten great results though with some absolutely nothing. Have 30 or so forms filled out. Frustrating when it doesn’t work for me though pleasantly amused when it does.
Hank
PS. Finishing this up at lunch. Though I had 30-40min this am , it wasn’t enough time. Told you my typing sucks.
Here are Bill's Stories for September
Case Studies TMR 16
New month…new stories…a few zebras…
I know a lot of PTs get the “heebie jeebies” (did I really write that…never used that term before!) when they get neck or back patients…well I only do when I get someone that has been referred to us from one of the pain management docs.
So what happens today? I get one. She has no reproducible neuro tension/compression signs. Female, mid 70s, basically hurts all over! She received a diagnosis of RA a few years ago. Her symptoms have been getting worse since Jan 09…pretty long time. Her diagnosis is (B) lateral hip pain…but there is more…(B) neck, shoulder, low back, and leg pain to the ankles.
So where do I start? Tom would say, “I bet with the twists and arm raises.” And he would be correct…hell why change now? Course if they don’t work there are other movements to check out.
She has tenderness pretty much all over. She has ROM deficits in the neck and low back. So after my exam I give her my manual therapy label of “right lumbar/SI/cervical dysfunction, left shoulder impingement”.
But now I have to find an issue. Stairs bother her knees and hips and her “right side doesn’t support her”. ROM of the neck, shoulders and back bother her. So I’m looking at all of that as “the issue”.
To make a long story longer…she does the rotations…gets more motion in the neck and back…less pain in the knees and hips with the step up. Next she does the arm raises…gets even more mobility in the neck and back but not only that…no pain. Her shoulder symptoms are gone. She is able to step up on either leg now. Still some symptoms in the knees but down from a 7/10 to a 2/10.
She is very happy now…she can’t believe she could feel so much more mobile after just a couple of exercises. I was going to add the leg raises…but I decide to let her just take in these two for now.
2nd visit: She hasn’t had any leg or knee pain since the first day. Yesterday she cut the grass and cleaned the house! This morning she had a little hip pain but the “exercises made it better.” Today she says her primary issue is her neck and left shoulder. So I show her a movement that works on most of the neck patients however it involves the hip (and knee, hamstring, glutes, low back, etc). I have her do 2 reps of 15 seconds of the standing knee flexion, hip extension motion. Afterwards she has no complaints in the neck or shoulder.
Very wicked…in a good way!
Female, early 40s. Has had symptoms off/on for over 3 years. Current episode began 3 months ago. No injury. Actually she didn’t have an injury 3 years ago either.
She said she was “scared to death” to come to therapy. She had therapy before but said it hurt and she cried every time she left. (Damn! Just what the hell are people doing out there!?) I told her she wouldn’t cry today.
She had no reproducible nerve tension/compression signs. Increased symptoms with sitting, walking, and lying down. Degenerative changes on XR/MRI and a “small HNP at T11-12”.
She can only bend forward enough to where her fingertips hit her knees and very little extension.
Of course with this type of a problem I do the twist first…she is happier…less pain and more motion. After the arm raises…big smiles…less pain…fingertips to floor and WOB extension.
I ask her if she feels like crying…she laughs instead.
Now here’s an interesting case…I guess some would label this as “chronic” pain as well.
Female, mid 30s. The left low back/lateral hip have been bothering her since ’07. She says she hurts 24/7 and gives it “8/10”. Also c/o (B) heel/ankle pain, right > left for one year. Job: Speech Therapist. Doesn’t sleep well. Symptoms are so bad she can’t stand too long and can’t sit. Best position is kneeling…so she kneels on pillows during the history. This is a first for me!
She has seen several docs and actually had a one level fusion done last year…and it did not help at all.
She has seen a few PTs along the way. Her first one hammered her on her posture. Her second one wanted her to “slump a lot”. Her last PT is McKenzie trained. She says he has helped her a lot because at least she can move backwards but her progress has really leveled off and she still can’t bend over, sit/stand for period of time. And her feet and knees are getting bad and she relates it to her back.
So she has no reproducible nerve tension/compression signs. She has a tremendous amount of extension (not just WOB but way, way, way on back!!) but when she bends forward her hands reach her mid thighs. Says she can’t remember the last time she could bend further.
I go out on a limb and tell her that she might touch her toes today…and in about 2 minutes. She doesn’t buy it. Hell I don’t blame her.
Yeah you know what I did…but do you know the results? Well you should by now!
She starts with the twists and then can bend to her knees…does the arm raises and bends to her shins. Says she can’t believe it and says she likes the way that I am thinking “outside the box”. I tell her that I really am not thinking “outside the box”…I just have a bigger box!
She is happy with the bend to the shins. But she just “looks” like someone that really could go farther. I show her the seated leg raises. She does 2 sets of 15 seconds holds. She then stands (its coming)….bends (wait for it)…(BOOM) touches her toes!
So she leaves with 3 exercises. She is amazed no one has ever shown her these exercises. I tell her if I had met her 17 months ago I couldn’t show them to her either…but it doesn’t matter…she has them now.
2nd visit: Says she is having some good and bad days but “that’s better than all bad”. Says the exercises help but she isn’t doing them as often as she should. Still has the (B) foot and heel pain. So we go over the exercises again. She is able to move better and her symptoms drop a few notches. She really doesn’t like the leg raises. So I show her some “chunking” on the side rotations…moving much smoother…plus her heel pain decreases “a little bit”. We “chunk” with the arm raise…as she walks away she says it got a little mo betta…Next I show her the single leg sit to stand, 2 sets of 10…she notices the quality of movement gets smoother. She then walks…turns around…walks back and has a seat and says, “The heel pain is 50% better.”
WoW.
Female mid 50s. s/p one level ant fusion 4 weeks ago. Says she did well for a few days then had problems with her legs and walking. She walks really “stiff legged”, slow small strides. We didn’t really do bending or extending…but “yes” for therapy we actually did rotations and arm raises. She walked around the clinic after each exercise and got better with her walking almost immediately. She was amazed…and so was I! Hell I didn’t expect that…but I will from now on!
2nd visit: She says she is better but still feels it in her legs when she walks or stands. I ask her to do her exercises. She does them without checking to see which side is easier. She also tells me she does them on both sides. After we clear up the misunderstanding she is able to walk much better again…and has a bigger smile on her face!
3rd visit: She isn’t feeling as well and thinks it may be the weather. Continues the exercises.
4th visit: Big smiles again…then tells me she is walking a mile a day. So she goes from maybe room-to-room in her house to a mile a day! All this in 2 weeks.
Bill Sent me this one in a seperate email a couple days after he had given me the above stories. I thought it was worth including.
Interesting thing happened here about an hour ago. Had to pass it on!
I got a patient from another therapist here. He had some issues with his squatting technique.
A little history. Male in his mid 20s, likes to lift weights. Was doing well but hurt his back a bit. Now his back is doing well but his hips and back "round out" when he gets around parallel (see photo for example). He scoured the internet and has done just about every stretch you can think of to alliviate his squatting "issue".
Since he had tried all things conventional I tried a heel lift...essentially a 2 x 4 under his heels. I knew it would help because it was my research project in PT school...but he doesn't want to lift with a heel lift.
So tried the seated rotations...not much change...
Next single leg sit to stand...FREAKING WORKED!!! This is one I shoulda/coulda taped! His face (as well as technique) said it all. Said it was the best the squat felt in a month!
I told Bill he needed to keep a camera near by and start filming these so everyone could see this stuff in action. Here was his response with another story.
Yeah...gotta keep a camera available and get over the "hurdle" of asking people if I can do it.
Another interesting thing happened this morning. A guy in our "golf performance" class hurt his back over the weekend and didn't think he could participate. My partner was looking at him and asked me to...so I ask the guy if he had done the rotations.
You see we use the rotations and arm raises to loosen the golfers up...kind of a "warm up"...works well. Anyway he had no idea they were for "therapy"
as well. So after the rotations he could touch his toes and after the arm raises he had full extension...
He said he wished he had been doing them over the weekend now but had no idea they would do anything.
Fun stuff dude!
That is all for September!
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“OK…here comes Bill again with some stories of people doing 2 exercises.” Hell essentially that’s about it…and why not? They work. But in thinking about my patients first and you (the reader) second I’m trying to get better at having the patients try and learn some of the principles behind the whole TMR thing. Hopefully this will help me to get better at TMR, maybe better at writing something interesting, maybe better at my feelings for my fellow man…or maybe not.
So as most of you know…the majority of my patients are spines…well they are more than just spines…much more now (to me) than before…as now I see the body as really more connected all the way and up and down, inside and out.
So here comes a woman, early 50s with (B) ant knee pain. The knee pain has been going on since Jan 08…that isn’t a typo…for over 2 years! The pain started during Body Pump classes so she stopped exercising totally. Her knees calmed down a bit but they still bothered her daily. Then she gets a rescue dog (German Shepard) and knows she has to walk the dog daily… thinking of bonding with the dog and shedding some pounds in the meantime. Well her knees flared up big time and have been bugging her since May 09.
The knees bug her with sitting, sit to stand, walking, standing, stairs…no ligamentous instability noted…mod tenderness (B) medial joint lines and (B) plica. I have her extend her knees while she sits. No major pain but her right hamstring “feels tighter”. I ask if her back bothers her. She says her back had been bothering her since her knees flared up but the knees were so much worse she didn’t mention it to the doctor. So now I have to think more globally…for my fellow man…er…woman.
I ask to stand and bend forward. She is only able to get her hands to her upper thighs as she bends forward. She has some extension but not much.
So at this point I already know (experience) that her knee symptoms may decrease but they won’t go away until we address the back.
The knees bothered her with stairs so I used this as her “issue” (TMR talk) of the day. ‘Course we’ll throw the back in there as well…but remember I’m not really “treating” the back.
I ask her if she would like to touch her toes in less than 2 minutes. She laughs and says, “Sure!”
I have her do the seated rotations (3 x 15 seconds). She bends forward and touches her shins. She comes up and says she can’t believe it! I know how she feels but I see it every day now. So I tell her to sit back down because we are running out of time. I only have 2 minutes! So now we do one rep with a little “chunking” for 20 more seconds. She stands…bends…fingertips hit the floor…and now she is floored! So less than 2 minutes.
Next…since we are treating the knees…she steps up the stair. The knees feel better. It is still there but not as much as it was a couple of minutes ago.
I then have her do the seated leg raise…since we are treating her knees…and after 3 reps of 10 seconds (she couldn’t hold it longer)…She stands and touches her palms to the floor…she then goes to the stair…(drum roll please)…all of her knee pain is gone!
Now I would be say this was all a bunch of crap if I first read about it…but I see it daily now. I still get a big kick out of the patients faces.
2nd visit one week later: The bad news…she has only been exercising sporadically. The good news…she had an MRI and had only degenerative changes. (I think the ortho guy really jumped the gun on this…ordering an MRI on two stable knee on the first visit…my opinion…nothing more.) Continuing the good news. Her left knee feels fine. She has no tenderness. She is able to walk the dog without symptoms later. The right knee still has some tenderness but barely. She can do a stair without any problems on the left and minimal on the right.
We “clean up” her exercises. After doing the rotations the right knee is better again…and after the leg raises the issue is gone again.
Pretty cool for a pair of knees that have been bugging her for over 2 years…at least I think so!
Female, late 20s, works as hairdresser. Has been having low back, groin and ant thigh pain to the knee since Mar 09. Seen the doc several times. Get this they even went so far as to take out her appendix about 2 months ago. Can you believe that??? She’s afraid to do anything so I decide to keep things just as simple as possible.
My findings: Right SI/lumbar dysfunction. No reproducible nerve tension/compression signs. Active lumbar flex: finger tips to her knees. No active ext. She just can’t do it.
After the seated rotations she could bend and get her fingertips to her shins and actually have a little extension. After the seated arm raises she almost gets her palms to the floor… and her extension? WOB (way on back). Big smile on her face. Says she can’t believe it. Asks me if she should keep her MRI appointment later on today. Damn this is cool! 2 exercises…pert near full ROM and a lot less discomfort. Took about 20 minutes.
Very, very interesting case (to me anyway).
Female in her 40’s. She doesn’t know the English language well. (And I don’t know hers.) She has an interpreter.
She was doing perfectly fine in life until she had surgery Feb 09. Type of surgery? Breast augmentation, tummy tuck, butt lift and lipo. Complete successful recovery from surgery (visually the surgeon did a great job)…except for severe (B) back pain and stiffness…self rated at “7/10” and the symptoms are constant. (I’ve been specializing in out patient spines since ’92 and this was/is a first for me as far as “mechanism of injury” is concerned.)
Increased symptoms with sitting, standing, sit to stand, walking, lying down, bed mobility…you name it and it hurts. Worse in the evening and can’t sleep through the night.
So here is a woman that paid several thousand dollars for completely “unnecessary” procedures that left her looking great but feeling miserable…and having to think about it and live with it for several months. Now that has to be some major internal stress!
She has no reproducible neuro tension/compression signs. The pain is (B). With my exam I label her with a “Left SI/lumbar dysfunction”. Again truly something I could easily mobilize and get her to feel better.
She can forward bend her hand to her upper thighs but has little to no extension. I don’t start with the Fab 5 form because of the amount of time I have, the language barrier, her “body language” and because I also know I can make a dent in her symptoms with 2 TMR exercises in my arsenal: the seated rotations and the seated arm raises.
I have her do 3 reps of both exercises at 15-second holds. After each exercise I have her stand and bend forward/backward. The rotations are first…she gets more motion. Next the arm raises and she gets even more mobility…boatload of extension and fingertips to her ankles.
She is smiling now…moving better…and has major symptom decrease. Next problem…I can’t see her for 3 weeks. She has a 3000 mile trip tomorrow. Damn!
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3 weeks later I get paged. I forgot about her over the past few weeks. OK…she’s baaaaack. I open the door to our welcome area and there she is…Smiling…Good sign! Gets out of the chair without any problems. Moves much quicker. And then she says “is feel” much better! Very nice to hear.
After 5 months of pain she gets 2 exercises and she doing so much better. She says she doesn’t really have pain but “aches”. Able to sit, walk, up/down stairs, sleep, essentially everything without much of a problem.
Upon exam no “left SI/Lumbar dysfunction”. I “clean up” her exercises and may see her again in about 10 days.
3rd visit: Still some aches daily but nothing like it was. “Clean up” the exercises again.
4th visit: 3weeks have gone by and she has cancelled several appointments. She returns 90% better. Has full ROM. Hell I don’t blame her for not coming! Her back only occasionally aches now and she is doing anything she wants!
I have some fun (fun may not be the correct term) when I get to treat other medical practitioners. I’ve treated nurses, physicians’ assistants, PTAs, occupational therapists/assistants, MDs, respiratory therapists, athletic trainers, massage therapists and yes physical therapists.
It’s really interesting that the doctors (physiatrists, orthopods, internists, anesthesiologists) I’ve treated never really cared to “figure it out” as much as the fellow therapists do.
So today I get a call from a physical therapist. I’ve known her for years and have seen her in the past for her back and neck. She called because she knew it could be an easy fix from a manual therapy point of view. It appears that yesterday she went for a walk and after the walk decided to pull some weeds out of the lawn. Her back started to get sore and got worse. This morning she couldn’t bend over.
No nerve tension/compression signs. She couldn’t bend forward…Nada…nothing. Her extension didn’t look too bad but maybe a small deficit. The pain was all right sided. I label her with a “right SI/lumbar dysfunction”.
She knows the PT “vernacular”. I ask her if she would like to move better in less than 2 minutes. She does. I see this as an opportunity to help my fellow PT and to educate her about TMR. So I don’t break out the form (surprised?) and I do start with (drum roll please) the seated rotations. (Hey I’ve got a good reason!!)
She does my typical 3 x 15 seconds. Afterwards able to rotate better and can forward bend with her fingertips to her knees. She still has some pain but not as intense and can move easier. I have her do another rep of the rotations with “chunking”. She can now rotate even farther on the “bad” side and can now bend to her shins. She is still getting the little “catch”.
The arm raise is next. After the 3 x 15 she can bend and touch her toes. 2 minutes up and she is feeling and moving better than she did all morning. Now she does feel the “catch” coming back up out of the full flexion she has gained.
So I have her do single leg sit to stand. She knocks out 2 x 10. Now bends forward/backward without feeling the “catch”. She has some soreness but not pain now.
I give her a copy of the exercises and we talk about me giving her place (home health) an in-service on TMR!
Sometimes it’s just hard to break away from something that works really well…like the manual techniques I use…and the seated rotations and seated arm raises. I just couldn’t help writing about this one!
Female, 21, College student and works as a server (we used to call them waitresses/waiters). Has had pain on the left flank since 2006. No injury noted. XR are negative except for a “mild thoracolumbar scoliosis”. She is able to use a gym 2 – 3 time a week and uses heat to relieve her side pain. She rates her pain at a “7/10” today. Sitting and driving make it worse.
No reproducible neuro tension/compression signs. Has some lumbar limitations in ROM but not huge. I find a “left lumbar/SI dysfunction”.
I chose to show her the rotations and the arm raises. Naturally her ROM increases and her symptoms decreased. She goes home with 2 exercises.
On her second visit she says she is fine. I ask her about her pain scale (“fine” isn’t on there!) and she says she hadn’t had any pain since her first visit but once. That was on a long trip. She did her exercises and it went away.
So 2 exercises “fixed” someone that had symptoms since 2006. I really get floored with some of this stuff.
Interesting again…Male, late 50s. Had disc surg 12/08…developed an infection…had another surgery to “clean it out” 2/09. Says his vertebra fused during the course of time. Has still been having pain since the last surgery.
Primary complaints: Right low back pain w/left calf “sensations”. Difficulty with sit to stand, walking, walking inclines, sleeping.
He has no reproducible neuro tension/compression signs. My exam finds a “right lumbar/SI dysfunction”. He could bend forward, fingertip to his shins. He couldn’t lean backward. He actually was a bit flexed with walking/standing.
I had seen him as a patient in the past. He felt like all he needed was for me to “stretch him out”…his term for manual therapy.
So here I go again…seated rotations…he doesn’t get more flexion but he is able to extend to neutral. Pretty cool in 45 seconds (3 reps 15 seconds each)! Then on to the seated arm raises…he can now touch his ankles and has full extension. He’s pretty happy. Says he hasn’t stood up straight in a year.
So I only want him to do these two exercises…but he wants me to “stretch him out”. So I “stretch him out”…he says it feels good during the “stretch”. He stands up and says, “You know…I think I like that exercise better.” So I have him do a couple more reps of the arm raises and he feels more comfortable.
2nd visit…3 days later…Reports doing 50% better overall and no leg symptoms. We “clean up” his 2 exercises. He says he still feels just a “little stiff”. I have him do the seated leg raises. He can only hold his leg up about 7 seconds. We do 2 sets. He feels looser. I then shoot for the single leg sit to stand…2 sets 10…Then he stands and moves around and says, “That’s it! Much better.”
If all I had in my “box” was manual therapy I would be very humbled, hurt or something. It’s very cool to see just how…should I say “powerful” this TMR stuff really is.
One of our vendors came in for the usual weekly clinic visit. I notice he has a TENS unit on (from his company of course). It seems the night before he was working around the house and tweaked his back. Proverbial “stiff as a board” presentation. I ask if he would like to feel a little better. Obviously the answer would be yes but he didn’t have a lot of time. I ask if he has 2 minutes. He does.
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By now everyone can guess what I do…Mostly a mixture of some TMR and some manual stuff. And as far as TMR goes: primarily the seated rotations and seated arm raises. Sure I’ve done a smattering of a few other “TMR movements”. But lets see if I can get good results by only using TMR. It means I have to step out of a comfort zone. And you can follow…hell it may even mean I’ll actually fill out a form. Maybe…
Male, early 60s. Diagnosis: lumbar stenosis, lumbar disc herniation. My label: Right lumbar/SI dysfunction. Says he is very stiff with bending forward or backward. Says his back doesn’t hurt much but is really concerned with his leg being numb from the hip to the toes. This has been going on since Thanksgiving and this is mid December. No injury. He is retired…
He can touch his mid thighs. No reproducible neuro tension/compression signs. Does have some weak ant tibs…say a 3-/5…has some problems with heel walking.
So you talk this case out to yourself…not much pain…does have “stiffness”…his major concern is the numbness. Personally I never know if I can ever help the “numbness” but I do know I can help the “stiffness”!
So yes we do the rotation and the arm raises. Afterwards he can touch just below his knees. He sees and feels a change. That’s enough for me for now.
2nd visit: You never know about these cases. He comes in looking happy. He is able to touch his mid shins now. He say he has no back issues stiffness or otherwise. The leg is doing fine. The only thing he has now is a little tingling in the toes…not too shabby. We review the exercises…call it a day…oh and then he shows me that he can heel walk without any difficulty.
Very cool, indeed!
Male, early 60s. Has had some back issues for years. Finally had a one level fusion about 8 years ago. His back has only bothered him 3 times since the surgery and only for a few days. This current episode is different. It has been going on for about a month. Has an office job and travels a lot by car.
No injury noted. Says he was really active the last weekend of November…getting firewood cut and stacked. The back just “went out on” him while he was sitting at his desk 2 days later.
He has a “mild” + SLR at about 45, “mild” sitting SLR…so maybe…just maybe he’s got a little nerve irritation along with a little lumbar/SI dysfunction. When I ask him to bend forward he laughs. Says there is no way…but he is able to get to his upper thighs. Has some extension but not much.
Everyone knows by now that I’ll start with the rotations then the arm raises…why change now since this works? After the rotations he can touch his mid thighs…after the arm raises he can touch his mid shins and get a lot of extension.
He can’t believe it…says so… I believe it…see it every day!
2nd visit: Says his symptoms are almost all gone. Negative SLR!
Early 40s, female, bus driver. Has had low back issues since the ‘90s. This episode started about 3 – 4 months ago. (B) LBP, right > left. Got an epidural several weeks ago that helped a little. Also has seen a chiropractor several times but no lasting results. No recent injuries.
Docs’ diagnosis: lumbar spondylosis. She says she has “scoliosis, several bone spurs and bulging discs”. My label: Right SI/lumbar/thoracic dysfunction.
She can bend to her upper thighs and has very little extension.
So she gets my BIG TWO exercises. She can move a little better. Not the big “miracles” that I like to get…but I’ll see her again in a few days.
2nd visit: She says, “Yesterday and today I haven’t had pain.” Not bad for 2 little, bitty exercises over the course of a week. Oh yeah…she tend bends over and touches her toes. Then leans way on back. The next question she has is “When can I get back to the body pump classes?”
Anytime…
Female, mid 40s. Works 12 hour shifts as an RN. (B) low back pain, left hip and leg pain to the knee. Lateral shift to the left. She says it all started about a week ago…gradually. She can’t remember any injury…but she did fall off a horse about 3 weeks ago. Contributing factor? Maybe…maybe not. Can only bend to her upper thighs and has no extension.
So after the big 2 exercises. She is able to bend to her knees and has a little extension. Not a huge improvement to me. She seems to be happy though and I am here for her…not me. I like to err in doing “too little”. If you do too little you can always add more later. If you do too much you kinda end up paying for it!
2nd visit: Doing better. She says she is straighter. I agree. Her leg symptoms are gone. She can bend to her shins now. I proceed with more movements, specifically seated leg raises and single leg sit to stand. No big changes in ROM but she says she “feels better”.
3rd visit: Says she’s doing great…has no pain. Can bend over and touch her fingers to the floor. Has more extension. Says she can feel it a little bit leaning backwards but not much. She’s happy and wants to start riding again! No lateral shift!
Very cool…and in a week and a half!
OK…sometimes we make mistakes. Last week I had a woman in her 80’s here to see me. Pain for years. Seemed frail. Used a cane. She’s had increased pain after a bad bout of COPD about 3 months ago.
Has (B) LB/lateral hip pain…constantly. My label: right lumbar/SI dysfunction. My “mistake”…I “felt sorry” for her…so I did the manual stuff and not the TMR stuff. I just didn’t want to go through the exercises with her. I didn’t think she could handle them even though we all know I would only start with the arm raises and twists.
Results…she felt a little better when she left from the manual stuff…which I knew she would.
2nd visit: She says she is doing a little better overall. But still a bit stiff on the right. Today I thought maybe…just maybe she could do some of the exercises. Interestingly enough when she did a seated hip flexion movement it was tight. I had her do the seated rotations and the arm raises. BOOM. No problem with the hip flexion. She stood up bent over and backwards more freely and walked across the room “easier” and without the cane!
Moral: If I really, really “felt sorry” for her…I should have given her the best advice/treatment I have to offer! Dammit!
TMR = Meaningful and Fun stuff.
You know it’s really meaningful when you can make an impact on someone’s life. And it’s really fun when you can make an impact in a very short period of time and when no one else has been able to (good for my ego as well).
That is what has been driving my PT career for years. I have been able to make a difference where others haven’t. But now that I am doing some of the TMR stuff I can make that impact even quicker and more often. I didn’t think that could happen but it has.
So I’ve been doing PT since ’87. Specializing in outpt spines since ’92 and doing it well…at least my patients say so (and their outcomes as well)…however there hasn’t been a single thing/technique/course/beer/ to impact the way that I practice until I took the first TMR course almost a year ago.
Male, late 40’s. Works as a contractor. Long hours and hard work. Says he “blew a disc” in ’82 and had pain off and on until he had a discectomy in ‘95. The surgery made things better but not well. Still had some problems off and on since the ‘95 surgery but not as intense. The past 2-3 months have been worse.
Symptoms (L) low back/leg pain to the calf. Sitting/standing/walking all make the back worse…sitting is the worst of all. Left hip flex 4/5, lumbar ROM: “hands to knees” flexion, little to no ext. No neuro tension/compression signs. Hard to get out of a chair.
Did my usual seated rotations/seated arm raises. He got a little more motion but not like I usually get. His symptoms decreased a couple of notches but that was about it. Yeah occasionally this happens…even to me. But I decided that was all I was going to give him.
2nd visit. Jumped out of the chair in the reception area. Stood up touched his toes, leaned way on back (WOB) and said, “This is the best I have felt since 1995. That twisting thing is the best thing I’ve ever done. I actually had one day that was completely without pain or being stiff. Today just a little tight and that’s all.”
That was meaningful…and fun. Cancelled his 3rd visit because he felt so well. Discharged after 2 visits.
Bartender. Early 40’s. Right low back pain/stiffness and anterior thigh pain and leg pain to the foot. No known injury. Symptoms have been going on since 2007. Increased symptoms in the mornings, with sit to stand, standing, lying down and walking. Past medical: HTN, (B) carpal tunnel surg, right RTC tear (unrepaired). MD diagnosis: Lumbar DDD.
Did the usual seated rotations and seated arm raises. She was able to move a little better the first day but not as much as I would normally have gotten with the two exercises. I opted to let her go home with just the two. Could have taken her through the rest but I “just had that feeling”.
2nd visit. Surprise! To the patient and me! Her range had improved greatly. She still had some back pain but the leg pain was gone. She actually did her exercises correctly. And incidentally…her right shoulder felt better as well.
Retired woman, late 60’s. (B) Low back pain and leg pain to the knees, (L) > (R). Symptoms have been going on since April of 2008. No specific injury but says she has fallen 2 – 3 times over the past year. Increased symptoms in the evenings and with sitting, standing, walking, bending forward/backward and difficulty sleeping. Diagnosis: Lumbar spondylosis and “pinched nerve” after her MRI and myelogram.
She has been seen here before after a RTC repair.
Started her off with the seated arm raises and rotations…but you already knew that. Her ROM improved but not greatly…I was more disappointed than she was so it was enough to let her go home with.
2nd visit: Reports she felt better and that the “exercises are helping”.
3rd visit: Reports she was doing “better until yesterday”. She went to a “ladies luncheon and sat on a bad chair and didn’t do her exercises as often as she should have”.
4th visit: Better but not well. She wanted some “strengthening exercises”. She got simply ab curls and bridging.
5th visit: Said she was doing really well. Had only occasional symptoms. Went shopping at the mall w/o difficulty, was sleeping better and able to stand and cook dinner.
All of this in 5 visits over 21 days…not bad since she had been hurting for about a year. She came in again after 10 more days. No pain…6 visits in a month and discharged.
Female, late 50s, works in office environment…about to be one of my biggest challenges…some challenges are overrated but I really like these kind…the patients that have been to other therapists, doctors, chiros, etc. These are what make my job fun.
She has a diagnosis/label from the neurosurgeon of “Lumbar DDD, bursitis”. Symptoms: Left Low back/hip/groin/knee/anterior leg pain/stiffness. Limps…has been using a cane for 3 – 4months. The back has been a problem off and on for over 20 years. The knee started about 3-4 years ago. The hip and thigh about 2-3 years ago. No mode of injury noted. No neuro tension/compression signs. She has problems sitting, standing, walking, sit to stand, getting in/out of bed or cars, bed mobility, all ADLs including: cooking, cleaning, showering…just not a happy camper!
She has seen a couple of family docs, 1 chiropractor, 2 orthopods, 2 pain docs, 2 therapists, and now a neuro surgeon that sent her to me. The first ortho guy ordered an MRI which came back with “DDD L3-S1 with moderate facet arthopathy”. He then tells her it isn’t a surgical problem as yet (which suprises me because I know the guy and he is a quick cutter). So he tells her it may be her hip. She sees the second ortho guy that says it isn’t her hip. Her pain or essentially “disability” made her to continue her search.
With my eval I find a left “lumbar/SI dysfunction” (my label). The patient can tell the difference during the eval which is important because there needs to be a change the first treatment. As far as flexion/extension is concerned: flex: hands to her upper thighs and little to no extension.
Anyone that reads this already know what I started with…the Sensational Seated Rotations. After doing my nonpatented scheme of “3 reps for 15 seconds” she notices that she can indeed turn to the other side easier. She stands. She is able to bend and put her hand on her knees and bend backward a bit. The she walks. Most of the limp is gone. She begins to “get giddy”. Hell I didn’t expect that much of a change but I’ll take what I can get.
So next? Yes the also Stupendous Seated Arm Raises. After the same unpatented scheme she bends…touches her toes then leans way on back…WOB: “Way on back”…my term for full extension.
She walks…limp gone. She says, “This is the best I’ve walked in months!” Way cool. Now at this point I could still do some manual stuff or even continue with some of the other Fab Five. Or I could let her bask in her newly found mobilty and pain decrease…which is what I did.
It’s really cool when this happens around other patients…but then most of the ones around here already know what is happening.
2nd visit: It is 5 days later. She says the two exercises are helping so much she has shown people in her office…best advertisement in the world! Hasn’t used the cane since the last visit. Has a slight limp as she walks in. I evaluate her as I did on the first day and find the same “label: Left lumbar/SI dysfunction”.
I have her show me the exercises. You can tell she has been doing them however she does not check to see which is the easy side. This has been something I have found fairly regular…since it is consistent I have to assume that it is my fault and will have to work on my instructions.
She does the 2 exercises and is able to walk a little better again. Today we’ll address more of her hip/anterior thigh pain. I have her do the seated leg raises and seated hip flexion. Both of which allow her better mobility on the left and walks without limping again. Very, very cool.
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28 yo, male…seen off and on since he was in high school…damn guess I’m getting older (but better…“that’s what she said”). Any way he was in banking and now out (not by choice…economy you know) and now happens to be killing chickens…for real, that’s what he’s doing now…at least until he starts teaching next fall. Thinks he tweaked his back with the chicken killing…who knows?
He assumes he has an “SI” problem again on the left side since he’s had a similar problem in the past and that is the “label” the doctor and I gave him. I agree with him this time but tell him I’m going to show him something different.
He then becomes “another one” that can barely bend forward or backward and after the two miracle exercises (seated arm raises and rotations) he’s moving like a champ. That is from almost no extension to full extension and from “hands to knee” flexion to the floor. Also with little to no pain.
He asks why I never showed him these before…I didn’t know them dammit!!!
Saw the wife of a spine surgeon today…he didn’t refer her but one of his partners did. I’ve seen her a few times over the years. In her early 30’s, has always been active…running and soccer primarily. Is on a co-ed team and a female team. Also actively owns 2 boutique stores. “Actively”…meaning she actually works.
Today she has right low back, lateral hip, leg pain, numbness and “heaviness”. She also complains of a “really tight right hamstring”. She can’t run and has a hard time bending forward at all…she gets to her upper thighs.
She’s a little bent out of shape. Not a lateral shift or anything but upset cause the orthopod shut her down for a week or two to get this under control.
She wants to get better faster. (Who doesn’t?) I tell her she will be able to move a lot easier in 1 min 30 seconds. She looks at me in disbelief…but she is curious.
After 1 min 30 seconds of the…you guessed it: SEATED ROTATIONS and SEATED ARM RAISES she is amazed…I’m not…not any more anyway.
As she bends forward she says, “Oh my god!” Then her fingers hit the floor.
She sits down and asks, “Why didn’t you show these to me before?”
---I didn’t know them dammit!!!
---Saw her for a follow up a week later. Says she has no pain just occasional stiffness. No leg symptoms. I show her “chunking” and she loves it.
---Another follow up 2 days later…she just finished running 3 miles. Also did some stationary biking. Still has some right ant hip “stuff” that comes and goes…but goes away with the SEATED LEG RAISES (yeah I do throw in some other stuff).
---Another follow up 2 weeks later…she just returned from Italy. So she had a long flight…lots of walking…and even ran about 1000 stairs the day before she left. How is her pain/issue…she feels a little stiff. She may be joining my crew for the brutal “Jonesercize” or as some of them call it “Jonesercide”.
Early 40s female. Office type work. L45 PLIF 9/08. Also has some other med stuff (an array of endocrine stuff, 2 y/o ankle surg, fibromyalgia).
Initial pain started after a MVA early summer of ’08. Had “therapy and injections” which didn’t help. The fusion in Sept did help but still having a lot of pain/stiffness. Has been getting therapy but requested to see me (yeah my head is getting bigger by the minute…).
Pain scale: 8/10, Lumbar ROM: could bend only hands to front of hips, little to no extension. Increased symptoms with sitting, standing, walking, rolling in bed…essentially you name it…
You know what I did…rotations…afterward able to bend to the knee and actually extend. After the arm raises she could bend to the shins and had essentially “normal” extension. She was amazed…especially after having therapy already and “no one showing me how easy therapy could be”. Symptoms dropped to a 4/10.
----2nd visit…symptoms stayed 4/10…so essentially a 50% drop that stayed after 4 days. Her ROM stayed the same as well. I introduced “chunking” today. One rep @ 15 seconds with the rotation (to the easy side) got her from her shins to her ankles…not a lot of change with extension. One rep @ 15 seconds of the arm raises got her fingertips to the floor and a boatload more extension…you should have seen her eyes…heck you should have seen mine! Pain to a 1/10.
---3rd visit…no pain just some stiffness.
Male, early 60’s. Weighs over 400 lbs…tall too! Problems going on since early March. No known injury…just “crept up on” him.
Issues: Low back, lateral hip, groin pain/stiffness. Using a straight cane to walk. Sitting, standing, walking, sit to stand, bed mobility, showering all bother him. Can’t sleep well.
Other stuff: HTN, DM, (B) TKR, stent.
Pain scale: 8/10, Lumbar ROM: could bend only hands to front of hips, little to no extension.
By now you know my plan…rotations…afterward was able to get to the knees and but no extension. After the arm raises he could bend to the shins and had extension…not much but it wasn’t painful. He started laughing. He couldn’t believe he’d been living with so much pain and all he had to do was a couple of exercises. Symptoms dropped to a 4/10.
----2nd visit… 3 days later. So he walks in without a cane…cool. Says he’s doing better and the symptoms stayed at a 4/10 and his ROM stayed the same. He shows me the exercises and is doing them well. I add chunking. He starts laughing like the first day. After the 2 exercises he is able to touch his toes…no kidding…the 400+ dude is touching his toes! He laughs harder when he extends cause it really looks normal.
So essentially “full ROM”. I asked about his pain…reply: “Nominal.”
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Here we go again…this time with some follow up to some interesting cases from the last batch of “mini-studies”.
This is a follow up on someone from last month. He’s the high school swimmer that had the odd chest pains…and the one that I started with TMR and finished with some manual stuff.
I go to receive him from the reception area (we don’t have a “waiting” room…we don’t like people to wait…so it’s a reception room…a room to greet people you enjoy or like to see…a place to “receive” people…another one of my soapbox themes). A big smile grows across his face…this is always a good sign!
Why the smile? Well he says he has no pain or discomfort…no issues. His pain at the initial eval was a “7/10” and now it’s “maybe a 1/10 sometimes”. Not too shabby! His father says he hasn’t complained about anything around the house like before…another good sign!
And now he is discharged…3 visits…2 weeks…cleared up stuff that’s been going on since 2007. Thanks Tom!
And another from last month…just to remind you…:
“Interesting case. A guy, early forties, sent to PT w/ diagnosis of “Lumbar DDD”. He also has some right-sided neck and shoulder stiffness/pain. Has had problems off and on for 10-12 years. Blames it on being in the army in the past. This episode started 12/08, no injury. The only thing he does for fitness is “stretching” on occasion. Refers to himself as “active” because he takes the stairs at work. Works in office environment. Past discectomy L4L5 in ‘05. Pain scale: “8/10”. Symptoms are intermittent but daily.
Issues/complaints/soreness/problems:
1. Central Low back pain/stiffness
2. (B) Lateral hip pain
3. Pain increases with sitting, standing, sit to stand, walking, bending (and probably a bunch of other stuff as well)
4. Can only bend to mid thigh
5. Almost no extension
6. Increased right side symptoms with left side bending”
So last month I mentioned his issues (above) and his second visit that his symptoms had dropped to a “0-4/10”. Well on his third visit he had no pain but “occasional stiffness”. Had essentially “WNL ROM”. I added “chunking” to the seated rotations and his “WNL ROM” got even better. He could actually “palm” the floor! Had no “stiffness” complaints any longer. I don’t do the “chunking” a lot but I plan on doing it more!
Another one discharged post 3 visits in 2 weeks…if I keep going like this I’ll have to get a part time job to pay the bills! Thanks Tom!!
How about a new one? Guy in his late 20s in a MVA a week before I saw him. Already has a lawyer. Interesting so far?
Has a manual type labor job. Increased symptoms with sitting, standing, walking, bending, lifting, sit to stand…essentially…you name it, it hurts. (B) LBP, (L) > (R). No neuro tension/compression signs. Pain scale day one: “8/10” and pain is constant. Limited ROM per acuteness. (L) hip flex hurts.
I find a Left “lumbar/SI dysfunction”. What did he get day one? You guessed it. Seated rotations and seated arm raises. And he felt better day one.
Day 2 a week later…better but not well. Still had some ROM deficits and needed some cueing on the rotations and arm raises. No problems with hip flexion. I thought about adding some more stuff but felt confident this was going to be enough for him.
Day 3 another week later…now says he feels “it” only about every other day. No pain today. Full pain free ROM today and he says he has started to work out again at home.
#3 discharged after 3 visits in 2 weeks…seriously thinking that this TMR stuff is working!!!
And now for something different:
One of the therapists working with me wanted my “manual skills” for a patient. Our egos are pretty small around here…Actually they aren’t that small…just had to say that in case someone I know really well reads this…but hey our egos only match the service we provide…which is HUGE!! Bottom line is getting the patient better and as fast as possible.
The patient is in his late 40’s. Office job. Likes golf but can’t play right now cause his back hurts. This episode started a couple of weeks ago. He was getting better but tweaked it somehow over the weekend.
Has a left “lumbar/SI dysfunction” in flexion…essentially he can’t bend. I asked my partner if he had shown the patient “the exercises”…yeah my partner bastardizes the TMR process more than I do…
Anyway the patient had been shown what to do but is not real compliant and admits it as I take him through the seated rotations. After 45 seconds (3 reps @ 15 second holds) he is able to bend with less discomfort and goes further.
After another 45 seconds of the seated arm raises (3 reps @ 15 seconds) he feels even better. Now he is getting it.
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I know it can get boring when you get a case (or read about one)…do 2 exercises…and BANG patients are better…but it’s just soooo cool. And when you see their faces…soooo cool. I can’t help it and I usually say, “Cool, huh?”
Interesting case. A guy, early forties, sent to PT w/ diagnosis of “Lumbar DDD”. He also has some right-sided neck and shoulder stiffness/pain. Has had problems off and on for 10-12 years. Blames it on being in the army in the past. This episode started 12/08, no injury. The only thing he does for fitness is “stretching” on occasion. Refers to himself as “active” because he takes the stairs at work. Works in office environment. Past discectomy L4L5 in ‘05. Pain scale: “8/10”. Symptoms are intermittent but daily.
Issues/complaints/soreness/problems:
1. Central Low back pain/stiffness
2. (B) Lateral hip pain
3. Pain increases with sitting, standing, sit to stand, walking, bending (and probably a bunch of other stuff as well)
4. Can only bend to mid thigh
5. Almost no extension
6. Increased right side symptoms with left side bending
So I find he has a Right lumbar/SI dysfunction in flexion and extension (personally I think they go hand in hand and that you don’t find them all by themselves…but hey…I could be…no I’m not wrong about this one). He also has a right sided cervicothoracic dysfunction…but hey I don’t have a script to treat that…I wonder it TMR will take care of that as well??
So I show him…as always…the seated rotations first. He does as I instruct…3 reps…15second each rep…always to the easy side. And as usual can rotate to the other side w/o problems and upon standing he can touch just below his knees and he gets a little extension. On his way up from bending forward you can already see it in his eyes…What’s going on here?…How can I move that well in only 45 seconds?
So next exercise…seated arm raises. Same instructions: 3 reps, 15 seconds each, easy side. Then I have him stand and he now has full extension and can almost touch his toes. His eyes bug out…How can this be? I’ve been hurting and couldn’t move for months and this guy shows me 2 simple things.
So I ask him to look up and then to the right. His eyes bug out. His neck is fine. Low back: 2/10 from 8/10…
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He’s baaaccckk. St. Pattys Day (a week or so from the first visit). Reports doing “much, much better” (as opposed to just “much better”). Symptoms range between “0-4/10”, no neck symptoms…pretty cool. Review his exercises. He’s doing them on both sides (arrrgggggg). We clean up his performance and he feels “even better”…
Cool, huh?
50 female, school counselor with back/leg pain since 2006 and is getting worse. Has a diagnosis of lumbar DDD. Difficulty with sitting, standing, walking, bending forward/backward, reaching w/o increased symptoms. No nerve tension/compression signs. Pain scale “5”. Can bend forward to her knees and not much extension.
I found: “Right lumbar/SI dysfunction”…in quotations now because I’m finding that like the doctors that give their patients labels/diagnosis, I have my own labels…I gotta come up with something else.
She is a bit apprehensive about therapy…I start her off with…you guessed it…the seated rotations to the easy side…3 reps @ 15 second holds. Her opposite rotation is now about even. She stands and is able to bend to her shins and has a bit more extension.
She’s amazed. 45 seconds of easy movement and she has less pain and more motion. So then she does the arm raise…3 reps @ 15 second holds. She stands and her finger tips hit her shoes and she bends backwards without pain and full range of motion. Hell…I’m even surprised this time. She sits down and says, “Now what’s your name again? I gotta tell more people.”
Her pain drops to a “0-1” with a minute and a half worth of work on her part…and after 3 years of pain.
Next interesting case this month…and this is an example of using TMR along with manual techniques…I couldn’t resist in this case…
15 yo, male. High School freshman. Complaint of intermittent (but daily) left “chest wall” pain since 2007. Wow!…was all I could say (why my schedule, Why!? Why!?)
Right dominant, on swim team, cardiac stuff cleared several times. Suggested to see us by pediatrician…shot in the dark probably.
He gets the pain with exercise and at rest. Can’t do butterfly stroke. Bothers him while sitting. The pain starts at the chest and goes around to the mid back (AHA!! Now we’re talking about something I’m familiar with.) Occasionally it bothers his shoulders as well. When it comes it stays for 20 – 45 minutes. Pain scale: “7/10”, Strength: WNL
Lumbar flexion: finger tip to the toes…now it gets interesting…with extension he goes back fine then the left side stops…yep stops but the right side keeps going…essentially since he can’t extend he rotates to the right…now I know what the problem is right there…at least spine wise anyway and I know I can make a positive impact…not sure about the chest yet.
So I find that his whole left side is very stiff…or we can call it a “Lumbar, thoracic, SI, cervical joint dysfunction”…there I go labeling again.
I ask him to show me a movement that might bring on his pain. And he says stretching his left arm backwards (horizontal abduction or you big word people)…Guess what I start with? Same movement on the easy side. 3 reps @15 seconds. He repeats the movement and his eyes bug out (lots of people here have eyes that buy out…I hope I’m not creating new problems)…the symptoms are still there but have dropped and his arm goes back much farther. His mom kinda freaked too. Very cool…So he now has exercise #1.
I then use my staples in my bastardized version of TMR…the seated rotations and the seated arm raises. Now he can put his palms to the floor and his extension has improved as well…but not fully.
So I jump off the TMR wagon and loosen up his lumbar/thoracic spine…now no restriction in mobility at all.
He’s back a week later…the symptoms come less often and less intense…symptoms down to a “3/10” when they come. He uses the 3 exercises during his swim practices and says he is swimming better.
Guess what he wants to know about now? His big question is how to get his chest bigger…must be the testosterone talking…not sure about the “cool” here…
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So what do you do? Answer: Nothing. He has no pain, no ROM deficits. About as “normal” as you can be. Bottom line is you treat the patient…not the scan.
Just a couple of interesting things…which are much more fun than the folks that just get better so easily.
39y/o male, has an office environment job, but does have to carry a gun from time to time. Live about 45 min from my place. Has had (B) low back pain since November ’08. No injury…just crept up on him. No neuro tension/compression signs. Does exhibit a right lumbar/SI dysfunction (most of you know what I mean by that…which is a bit different than what is taught in school or most courses…but then again…how much of the schooling was as good as the stuff you learn after you graduate?)
Increased symptoms with sitting, sit to stand, driving, standing or walking. Could only bend forward to where his hands were on his upper thighs. He could force himself through it…I know because he did. Don’t know why. I didn’t ask him to…Anyway
I figure I’d start with the seated rotations…CRAP…didn’t work…actually it did but nothing like I normally would get. So went to the arm raises…CRAP…didn’t work!! Well actually it did but still not enough to where I’d want him to leave yet.
So…single leg squats…I have him do 2 sets ten…he gets up bends over…hits his toes…does it 2 more times. Says he can’t believe it. That it was about 90% gone. Heck I usually would have let him to but I show him the bent knee toe reach (still trying to think of a better name for this one)…does 2 reps 15 seconds…bend over. Says it’s all gone. He looks at me…dead in the eyes…“So where is the hidden camera? I can’t believe it’s gone.”
So no manual stuff…2 exercises…and not the 2 that I usually give out.
RN, 66, female. Diagnosis: Lumbar stenosis, neuropathy. Course that’s just her “label” as far as I’m concerned. Has had symptoms since 9/08. Seen 6 times so far this go round. She hasn’t been in for 2 ½ weeks…too busy she says (not hurting bad enough I’m thinking). She’s a talker. Occasionally I get a few words in…no big deal, I’ve known her for a long time and have seen her probably about 4 or 5 times over the past 10 years.
During the “conversation” she says she can’t do “all of the exercises” because she is so busy but her symptoms are much better. So how much? She says she about ¾ of the way there…so I ask/say, “So you’re 75% better then?”… “Oh no” she replies, “I’m at least 90 to 95% better!”…Math not a strong suit I guess. As far as her symptoms go that’s just it…they come and go and are not there sometimes for a few days.
So I ask her “What exercises do you have time to do?” She says, “The twists and raising my arm.”
Toms’ got to be feeling pretty cool right now…I know I am.
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1. 41 yo male. Over 300 lb but tall too. Actually carries the weight well. Doesn’t look over 250. Pain in the neck, shoulders, back, hips, knees, ankles. Dx for about 3 years of ankylosing spondylitis and arthritis. Hasn’t worked in 6 years. Spine not fused. Sitting, standing, walking, sit to stand, rolling in bed all increase symptoms.
Does exhibit (according to me) a left sided thoracic/lumbar/and SI dysfunction…meaning (to me) that he can’t move “3 dimensionally in ext/sb/rot or flex/sb/rot” on the left side.
Active ROM extremely limited. Essentially lumbar flexion and his hand hit the front of the hip sockets and he had no lumbar ext.
Treatment: Skipped out on the manual stuff and started with the seated rotations. He was then able to flex where his hand hit his lower thighs…almost to his knees. He was able to extend just a little. And these were not just my observations but his and his wife’s as well. Then did the seated arm raise. one of his shoulders had been bothering him more than the other anyway. So easy side only. Did the 3 reps at 15 seconds. Lo and behold able to lift up the opposite shoulder and now able to flex to the shins and could extend.
Now I am not treating the anklylosing stuff…I think a lot of people get caught up with all the diagnosis of DDD, DJD, “bulging/herniated/protruded discs”, spondylolisthesis, old compression fractures, arthritis, postures of every conceivable angles…and most of these “labels” are just that…a label…My soapbox.
So he’s got a couple of things to do and I’ll see him again later on this week.
2. 64 yo. 2 weeks post op lum lam. Had symptoms for 8 –9 months before he had surgery. Today he has some tightness but no “real” pain. He could actively flex to his knees and could extend a little before he felt the “tightness” kicked in. He is retired military but still works in an office environment. Another big guy.
Exhibits (according to me) a right sided lumbar/and SI dysfunction…meaning (to me) that he can’t move “3 dimensionally in ext/sb/rot or flex/sb/rot” on the right side.
Skipped out on the manual stuff. Did the seated rotations and just like the other guy got a bit more motion. He had that look on his face of “non-belief”. So I go to my #2 exercise the seated arm raises. Now here comes the interesting stuff…one of his shoulders had been injured since he was 19. You could see the bump in his clavicle where it was broke at one time. He had trouble with flexion and internal rot. He could only put his wrist on his ilium. …I didn’t look at ER because heck I’m doing the post op back thing! Any way I get him to do the arm raises (on the easy side), 3 reps 15 seconds. At the end asked him to raise the other arm and he could easier and farther. Then he reaches back behind him and says, “ I can touch my spine! You must know what you are doing.”
That’s my job…sometimes I wish I did know what I was doing.
3. Saw this girl last week. 18 yo college student. HNP L5S1 on MRI. + Sit slr, slr, CRAM maneuver, bowstring. She is not active or fit. A bit overweight. Although the symptoms started about 3 weeks ago she was still in a major acute stage. Can’t sit, stand, lie, sit to stand w/o increasing symptoms. Started her with the arm raises and rotations. Her ROM was pretty much not there. After treatment she felt “better but not well”.
Today she could flex to her knees and extend. She had symptoms at her present end ranges. Added the bent knee toe reach (see Tom I am more than a “2 trick pony”…not sure if I’ll teach her the form yet though) and it helped. Tried the leg raise…didn’t help. So I pull one out of the bag…I remember at the webinar that Tom talked about his brother in law with the shoulder problem and did the “horizontal translation” thing. So I think what the heck we’ll try that. Well she liked it. So she has 2 more exercises that increased her painfree ROM. She is happy for once in 3 weeks.
4. Going back to the weekend. I train some adults…me included. We’ll probably have a web site up eventually. Everyone is over 30. At first it was over 40. We do nothing in moderation. It is pure hell. And I make it that way. Results come from action and effort. Anyway one of the guys has had a shoulder/neck/elbow problem off and on for years. The elbow won’t go into full ext or full flexion. The shoulder has a partial RTC/labral tear. And the clavicle has an old bump from a fx. He’ll be 50 in about 6 weeks. Doesn’t want surgery and doesn’t want to stop working out. He’s done some TMR on his own…never enough so I usually work on him manually before and after the sessions. But Saturday I remember Toms’ bro-n-law and have him do that side shifting thing lo and behold worked like a charm.
We’ll see how he feels in about 3 hours. That’s when we all meet to exercise hell again.
So the guy comes in and I ask him how his shoulder is. He says it sucks. I ask if he has been doing his new exercises and his face goes blank. Immediately he starts the side gliding thingy. He started feeling better and then we jumped into the fire. I didn’t have to work on him manually. I did verbally however.
What I got:
Patient: Male, Late 70s, X-military. Used to run a lot up until a couple of years ago. Developed some type of neuropathy. Also stenosis (symptomatically and radiographically). Had lum lam last year. Did well until about a month ago. Started to have moderate to severe pain. Very limited ROM. Pain scale: 9/10. No neuro tension/compression signs.
What happened:
1/26 was his initial visit. I had seen him before about 3 years ago. Did the manual thing along with the seated rotations and seated arm raises. These 2 moves have become about a 90% thing that I do with lumbar problems. So he feels a little better with about a 50% gain in range in active flexion/ext. A few weeks ago I may have sent this little “case study” out earlier but it’s beginning to get a bit expected on my part…and perhaps on your end as well…you know here’s Bill telling me what he got…did 2 exercises and created a little TMR miracle.
But hey keep reading.
The guy comes in for session 2 on 1/29. Says he did OK for about a day. Could barely move again now. Had little to no flexion or extension. He says he has trouble putting on his shoes and attempts to illustrate that by trying to bend his knee up while he is sitting. Essentially a single knee to chest while sitting. (Which is a move I use to gain increased flexion of the knee…on the easy side only!) Well he can’t do it on the right…he can on the left but it hurts the right side. Since I already know he’s doing the exercises and knows how to do them I gotta think about something else. (I also have to be good at this since I’ve treated his wife before and his daughter is a PA.)
So we try the single knee sit to stand. Tom just popped in my head with the Nike slogan, “Just do it!” Both sides are wobbly because of the neuropathy. I make the mistake saying that we know the right side was the worst…thank Godness I checked both sides. His most painful side of pain and the one he couldn’t pick up ended up being the “easy side” for the sit to stand. So he knocks out 2 sets of 10. Stands up and bends over touches his knees and is able to bend backward easier…all w/less pain. He is amazed. I am more glad than amazed. I have him do it for another set of 10 and the second set at 5. He now bends to his shins and full ext. Now he also has no pain. He is able to sit and bring his knees to his chest to put on his shoes w/o pain. Time so far: 10 minutes. So what do I do? He’s happy. I’m happy. Is doing more stuff going to accomplish anything? So I have him repeat all the previous motions: standing lumbar flex/ext/sb and seated flex/ext/sb and knees up. Still all w/o symptoms. He’s outta here in less than 20 min. Not that this is a speed thing or anything. It just worked out that way.
Now for something different…
I have an 76y/o recovering from a compression fx. Doing some TMR for pain. But this isn’t about her. It’s about her grandson. He had RTC surg in Oct and is having therapy somewhere else in town. While his grandmother is doing some exercise I ask him how his shoulder is doing. He says fine and raises his arm…gets around 150 and says it gets tight there. So I ask him if he like to do an exercise with his grandmother. You may get the picture…he does the seated arm raise (on the easy side of course) and 3 reps at 15 seconds a piece has no tightness and bicep by his ear. His eyes kinda bugged out like the guy on You Tube.
Some people may ask did I “treat” him? I think he just copied his grandmother and the forces of the universe did wonders for him….
Now for something different…
I’m thinking about how I could start teaching a DTMR…Dynamic Total Motion Release. Maybe I could go on the road w/Tom. I could be the opening act or something.
I have a pt that I have seen over the years off/on. Lives a little over an hour from my place. I usually do my regular manual stuff and she’s on her way. Anyway I show her the arm raises and seated rotations and she actually does them! The interesting thing is…she says the rotations help her while she walks (for fitness). So I ask her does she sit down on a bench or something? Nope…she said if she feels her back “hurting or tightening up” she twists while she walks. She was quick to say she only twist to the easy side. Then it loosens up and she keeps on going.
DTMR pt #2. A new pt to me. Has a neck thing going on. Medium story short: on the second visit he says he’s better and that he does the arm raises while he walks.
So if you come down south and see a girl walking while she twists and a 65 y/o male walking his 2 miles while doing an occasional arm raise…you know where they’ve been.
Life is interesting.
You may have noticed that I have a boatload of outpt neck/back folks. I have been specializing in this area since ’92…I would say that probably 95% of what I do is spine stuff with some shoulders/hip/knees/elbows if they are associated with the spine. Occasionally I do a “knee” or “shoulder” by itself. In our clinic we have another PT that does spine 100%, 2 other PTs that are more extremity bound…even they are about 50/50 spine and we have a PTA that has about a 50/50 patient load as well. We treat every one in an open gym area except our spine only PT…she prefers a room. So that brings you up to speed with my environment.
And we do sports enhancement. Essentially we have high intensity ex programs. Most of the participants are athletes from 10 y/o to high school to college and a few minor league ball players. We also have some arena foot ball players as well.
I train some of my friends with me…we kinda call it “Over 40 Only” although everyone is over 48. Male and female included. It’s part of a new blog that I haven’t had time to create yet. And we do bust ass.
Here’s some more TMR stuff.
What I got:
Female, early 40s. Yoga Teacher. Equestrian enthusiast (B) low back pain, left > right. Symptoms off and on since 2001. Saw me last year. Progressed well. This episode started after a 2-3 month illness. Docs said she had “walking pneumonia”. She eventually was treated with prednisone and is still on low dose. Has returned to teaching the past couple of weeks. I had talked to her during her illness about 6 weeks ago as she was worried that she would come back to see me as bad as she was when we first met. Me, being the positive force in the universe, told her not to worry about such things and get well. Well she did get better but she has some stiffness and soreness around the typical SI and thoracic area. I was pumped that she bounced back fairly well from the illness as was she. Increased symptoms with sitting, bending, sit to stand, standing, running, bending forward/backwards and walking. Today symptoms were a “6 out of 10”.
What I found:
Left thoracic/lumbar/SI dysfunction in extension/flexion…which for me means she cannot move into ext (L) or into flex (L). No reproducible neurotension/compression signs.
What I would usually do:
Fix the thoracic/lumbar/SI/cervical stuff with manual/ex and give a home ex program. At the end of the treatment the patient would feel better but not 100%. I usually see folks every 5 – 10 days, give or take.
What I did:
Started with the “Tantastic Two” (seated rotations, seated arm raises) because it’s just what I have been doing and getting a good reaction…they are the easiest to do for the greatest initial return. I had her do 3 reps, holding 15 seconds each, then check the “bad” side and then recheck the standing flexion/extension. Usually after the rotations they get more flex/ext but even more after the arm raises. And it worked again today. She being the yoga teacher could already touch her toes well but more relaxed after the rotations and palms down (hell almost elbows!) after the seated arm raises. After the TMR I went ahead and did some manual stuff…since she tends to expect that from the past. I’m not sure if I’ll see her again this year. She said she felt so much better and the new exercises seemed so effective that she may see me sometime in the next year.
What I got:
Male, High school basketball player. Sprained right ankle Friday. Has been non-weight bearing since because his mother was afraid of a break. She didn’t want to go to the ER and waited until today(Monday) to see a friend who is an orthopod. No fracture on XR. He’s a decent ballplayer. In the11th grade and already being looked at by several D-1 schools.
What I found:
Mod swelling and limited ROM…typical thing. More pain with dorsiflexion around the post/lat malleolus. On crutches. NWB secondary to pain.
What I did:
TMR wise: first resisted dorsiflexion on the well side, 2 reps 10 second holds. He was then able to dorsiflex affected ankle w/o increased symptoms. Attempted single leg sit to stand. Had the obvious result…that is he couldn’t do it and it hurt. So did 2 sets of 10 on the good side. His mother was watching by the way…next thing you know he could do it on the affected ankle. Both were amazed. He was then able to walk WBAT (weight bearing as tolerated) w/crutches. Went home w/some ROM stuff, ice/elevation, TMR: resisted dorsiflex on opposite side and sit to stand on good side.
It’s easy to fall back into “everyday” PT. Its really cool to see how much difference things can make w/TMR.
What I got:
Male. Late 70’s. Has right low back to mid back pain since May ’08. Says that it will go away for a few days but comes right back if he does anything active. And he is active! Likes to drive a few states over for some gambling and he owns a small farm. He has also been diagnosed with peripheral neuropathy. Has numbness/tingling (B) LE from the knees down. This has been going on for years. No better, no worse. Increased back symptoms with twisting, bending forward/backwards and walking. Today symptoms were a “7 out of 10”. When he bent forward his hands stopped on his upper thighs to support himself because of pain.
What I found:
Right lumbar/SI dysfunction in extension/flexion…which for me means he cannot move into ext or flex (R). No reproducible neurotension/compression signs.
What I would usually do:
Fix the thoracic/lumbar/SI/cervical stuff with manual/ex and give a home ex program. At the end of the treatment the patient would feel better but not 100%. I usually see folks every 5 – 10 days, give or take.
What I did:
Started with the “Tantalizing Two” (seated rotations, seated arm raises) because they work! Consistently the seated rotations get more flexion but when followed with the arm raises you get even more flexion plus extension…more bang for the buck. He did 3 reps, holding 15 seconds each, then recheck the “bad” side and then recheck the standing flexion/extension. After the rotations he was able to bend to his knees. After the arm raises he was able to bend to his shins. He then asked where I’d been all this time! He was elated to say the least. I didn’t do anything manual with him. Hell he was just too happy. He leaves on a gambling trip and won’t be back until the first week in Jan. I’m kinda curious to see if anything happens with his “neuropathy” symptoms.
So at the end of yesterday a PA that trains here was asking about her hip. She kinda has a little snapping thing. Since she’s a PA and asking a legit question and it was at the end of the day…I took her through the “Tenacious Two”. She got a tremendous amount of mobility back in her low back, hamstrings, and hips. She was amazed. Very cool ending of the day! Took 5 minutes.
What I got:
Female, early 50s. Teacher. (B) low back pain. Symptoms off and on since 1/08 increased after falling on a knee about 4 weeks ago. Increased symptoms with sitting, bending, sit to stand, standing, running, bending forward/backwards and walking. Today symptoms were a “6 out of 10”.
What I found:
Left lumbar/SI dysfunction in extension and right in flexion…which for me means she cannot move into ext (L) or into flex (R). No reproducible neurotension/compression signs.
What I would usually do:
Fix the lumbar/SI/cervical stuff with manual/ex and give a home ex program. At the end of the treatment the patient would feel better but not 100%. I usually see folks every 5 – 10 days, give or take.
What I did:
Started with the “Terribly Terrific Two” (seated rotations, seated arm raises) because it’s just what I do…they seem to be the easiest to do for the greatest initial return. I have folks do 3 reps, holding 15-20 seconds each, then check the “bad” side and then recheck the standing flexion/extension. Usually after the rotations they get more flex/ext but even more after the arm raises.
Result?:
I saw her 2 visits. The spacing between visits was 10 days. She was symptom free yesterday, dressed in heels and fingertip hit the ground. Started her back in the gym and walking that she hadn’t done in months.
What I got:
Female, 70. Retired. (B) low back/neck pain with feet and legs “always hurting”. No known injury. Symptoms started mid October. She “woke up and couldn’t move”. Increased symptoms with standing, bending, moving head, reaching, sit to stand and walking. Today symptoms were a “9 out of 10”.
What I found:
Left lumbar dysfunction/Right cervicothoracic dysfunction. No reproducible neurotension/compression signs. When she bent forward she had increased symptoms and her fingertips were midthigh. She couldn’t bend backwards. She couldn’t look up and at least 50% decreased (B) rotation in the neck.
My evaluation can be considered a “functional eval” in that patients move, blah, blah, blah, yada, yada, yada. Anyway what I find they feel and agree with me. Then I fix it.
What I would usually do:
Fix the lumbar/SI/cervical stuff with manual/ex and give a home ex program. At the end of the treatment the patient would feel better but not 100%. I usually see folks every 5 – 10 days, give or take.
What I did:
Gave her the “Terribly Terrific Two”! After the rotations she bent to her knee caps…after the arm raises she bent to her shins and was able to extend her back with out making a face. Actually the face she had now was a big smile. She was able to see the ceiling and rotated much further. So I didn’t even show her my patented neck thingy. You know you get this result and symptom relief and you have to ask yourself how much further should I go…so I stopped because she was so happy and I’ll see her in a week.
What I got:
Female, Late 60s. Retired. (B) low back/neck/thoracic pain/stiffness. All complaints have been going on for about a year. Increased symptoms with sitting, bending, standing, sit to stand, driving, moving her head and walking. Decreased sleeping. Prior back surg about 25 yrs ago. Today symptoms were a “7 out of 10”. She is someone I have treated about 2-3 years ago. She said she should have come back sooner.
What I found:
Left lumbar/SI/cervicothoracic dysfunction. Basically stiff as a board. No reproducible neurotension/compression signs. Could hardly move forward/backward or sideways in the back or the neck.
My evaluation can be considered a “functional eval” in that patients move, blah, blah, blah, yada, yada, yada. Anyway what I find they feel and agree with me. Then I fix it.
What I would usually do:
Fix the lumbar/SI/cervical stuff with manual/ex and give a home ex program. At the end of the treatment the patient would feel better but not 100%. I usually see folks every 5 – 10 days, give or take.
What I did this time:
Started with the seated rotations. She got a lot of relief all the way around just with this! I did do the manual thing with her because she expected it from the past however she was very impress with the exercise. She also mention that her husband was “in love with you”. He was one of the TMR only successes from one of the past “case studies” I sent out. The older golfer dude. Actually she told me her husband tried to teach her the exercises but she wanted to get them from me. She also said her husband got in trouble from her daughter. It seems the daughter is having some “minor” surgery and wanted the parents there. He asked if it was alright if he came by after his golf game.
What I got:
Male, Mid 60s. Office work. (B) low back pain. Occasional left leg symptoms to the foot. No known injury. Symptoms have been going on for 10 years. Has had epidurals, facet injections, SI injections, trigger injections. Has been seen by a lot of doctors and PTs in the past. Lives 2 hours from me. Increased symptoms with sitting, bending, standing, stairs, dressing, reaching and walking. Today symptoms were a “6 out of 10”. Increased symptoms with bending forward and backward. Stiff with sidebending.
What I found:
Left lumbar/SI dysfunction. No reproducible neurotension/compression signs. Bending forward he got to his thighs. Little to no extension.
My evaluation can be considered a “functional eval” in that patients move, blah, blah, blah, yada, yada, yada. Anyway what I find they feel and agree with me. Then I fix it.
What I would usually do:
Fix the lumbar/SI/cervical stuff with manual/ex and give a home ex program. At the end of the treatment the patient would feel better but not 100%. I usually see folks every 5 – 10 days, give or take.
What I did this time:
Started with the “Terrific Two”. I almost automatically just start with the seated rotations (twist) and the arm raises. It’s a quick buy in from the patient because of the result. After the twist he could get to his knees and after the arm raises he could get to his shins. He said that was the farthest he had bent without pain in years. I did do my manual stuff after ward to increase his ext a bit more. Now I’m still seeing all of these folks within 30 minutes.
Female, early 20s. Lives 2 hour south of here. Office type work. (B) low back/neck/shoulder pain. Occasional hand numbness/pain. Going on since May 08 and getting worse. No known injury. Was initially seen by a couple of kidney docs, then family docs, sent to me by a neurosurgeon. The only things that have helped were pain pills. Today symptoms were a “10 out of 10”. She attended her appointment with her mother. I told them I could tell them today if I could help her or not…which they were actually relieved to hear.
What I found:
Left lumbar/SI dysfunction in extension and right in flexion. Right cervical dysfunction in ext/left in flexion. No reproducible neurotension/compression signs. She could move fairly well but she was one of those “hypermobile” folks…you know the ones that hyperextend at the knees and elbows. Those folks usually have a lot of motion at the neck and back as well. She could bend well forward but not so much with backwards or ext in the neck. So since I found something to work on I could tell them she would get better…but how much I couldn’t predict.
My evaluation can be considered a “functional eval” in that patients move, blah, blah, blah, yada, yada, yada. Anyway what I find they feel and agree with me. Then I fix it.
What I would usually do:
Fix the lumbar/SI/cervical stuff with manual/ex and give a home ex program. At the end of the treatment the patient would feel better but not 100%. I usually see folks every 5 – 10 days, give or take.
What I did:
Started with the “Tremendous Two”. I’ve been getting good at 2 exercises. Maybe after 10,000 hours I’ll cut it down to one exercise! She got a lot of her lumbar ext and neck ext back. Also got back more neck rotation as well. Went ahead and did the manual stuff and she got even more ext/rot back. Mother/daughter happy at the moment. Coming back next week.
What I got:
Female, Late 50s. Prior pt of mine that I haven’t seen in about 3 or 4 years. Office type work. (B) low back/neck/shoulder pain. Diagnosis of “Cervical/Lumbar Spondylosis”. Symptoms going on for 2 weeks and getting worse. I’m not much into the posture thing but she is extremely kyphotic, forward head kinda thing. No known injury. Today symptoms were a “5 out of 10”. Had a RTC repair on the right side in 2002.
What I found:
Left lumbar/SI dysfunction in flexion and right in ext. Right cervical dysfunction in ext in flexion. No reproducible neurotension/compression signs. I haven’t seen her in a long while and she said she had been doing well until a couple of weeks ago.
My evaluation can be considered a “functional eval” in that patients move, blah, blah, blah, yada, yada, yada. Anyway what I find they feel and agree with me. Then I fix it.
What I would usually do:
Fix the lumbar/SI/cervical stuff with manual/ex and give a home ex program. At the end of the treatment the patient would feel better but not 100%. I usually see folks every 5 – 10 days, give or take.
What I did:
Started with the “Tremendously Terrific Two”. She got at least 50% better in the back and neck with subjective complaints. She also remarked how much easier it was to move her right arm…the one s/p RTC surg from 2002…very cool!! Did the manual stuff for the neck and back only and she got even more of a decrease in symptoms. Coming back next week.
What I got:
Male, early 30s, Symptoms since the beginning of Sept 08. Originally had (B) LBP, (B) groin pain, (B) thigh pain to the knees. No known injury. MRI: L5S1 DDD w/right protrusion. Treated by neurosurgeon with dose pack and now on Mobic. Most of his symptoms cleared well with the dose pack. Today had pain scale at “5 out of 10” but just the central area of his back. Primary complaint was stiffness. Job: on his feet all day, some type of inspector. Not a lot of lifting or bending. 300 lb but about 6’5
What I found:
Left lumbar/SI dysfunction…yep the left side not the right as the MRI had found but of course we are talking about 2 different things. He had decent mobility for a big guy. Again not a lot of pain today but stiff. Could bend to his shins and had some extension restriction.
My evaluation can be considered a “functional eval” in that patients move, blah, blah, blah, yada, yada, yada. Anyway what I find they feel and agree with me. Then I fix it.
What I would usually do:
Fix the lumbar/SI/cervical stuff with manual/ex and give a home ex program. At the end of the treatment the patient would feel better but not 100%. I usually see folks every 5 – 10 days, give or take.
What I did this time:
Started with the “Terrific Two”! He sat down did 3 reps of the twist, holding 15 seconds each. He was then able to bend to his ankles. Then did the arm raises the same way. He was then able to bend and his fingers hit the floor.
This took 19 minutes total. He was very happy and left with a “1 out of 10”. Hell I don’t even feel that good!
What I got:
Male, early 30s, Symptoms since the beginning of Sept 08. Originally had (B) LBP, (B) groin pain, (B) thigh pain to the knees. No known injury. MRI: L5S1 DDD w/right protrusion. Treated by neurosurgeon with dose pack and now on Mobic. Most of his symptoms cleared well with the dose pack. Today had pain scale at “5 out of 10” but just the central area of his back. Primary complaint was stiffness. Job: on his feet all day, some type of inspector. Not a lot of lifting or bending. 300 lb but about 6’5
What I found:
Left lumbar/SI dysfunction…yep the left side not the right as the MRI had found but of course we are talking about 2 different things. He had decent mobility for a big guy. Again not a lot of pain today but stiff. Could bend to his shins and had some extension restriction.
My evaluation can be considered a “functional eval” in that patients move, blah, blah, blah, yada, yada, yada. Anyway what I find they feel and agree with me. Then I fix it.
What I would usually do:
Fix the lumbar/SI/cervical stuff with manual/ex and give a home ex program. At the end of the treatment the patient would feel better but not 100%. I usually see folks every 5 – 10 days, give or take.
What I did this time:
Started with the “Terrific Two”! He sat down did 3 reps of the twist, holding 15 seconds each. He was then able to bend to his ankles. Then did the arm raises the same way. He was then able to bend and his fingers hit the floor.
This took 19 minutes total. He was very happy and left with a “1 out of 10”. Hell I don’t even feel that good!
What I got:
Fem in her 50s. MVA, Mid October. She started here the first week of November. (B) Neck pain, right > left. (B) Shoulder pain, right > left. (B) LBP. Left LE symptoms to the left heel. (B) HA, Left > Right. Right arm symptoms to the forearm. Constant symptoms. Can’t sleep. Increased symptoms with sitting, standing, walking, sit to stand, driving, ADLs. No past surg. + DM. Pain described as severe and “7 out of 10”. Works as “utility operator” which was described as having to be on her feet all day and lifting up to 50 lb, sometimes overhead. She looked like a nightmare in the waiting room…could hardly get up…when she did she looked like she was 90y/o (whatever 90 y/o looks like)…very slow walking…could hardly sit down again for me to start asking questions.
What I found:
ROM- Lumbar flex: -75%, ext: -75%, sb/rot: -50%(B); Neck flex: -15%, ext: -50%, sb/rot: -50%(B), (B) shoulder flex: 85 Strength- (B) UE/LE grossly 4-/5, possibly due to pain. Gait- Left lumbar/SI, Right cervicothoracic dysfunction
My evaluation can be considered a “functional eval” in that patients move, blah, blah, blah, yada, yada, yada. Anyway what I find they feel and essentially agree with me. Then I fix it.
What I would usually do:
Fix the lumbar/SI/cervical stuff with manual/ex and give a home ex program. At the end of the treatment the patient would feel better but not 100%. I usually see folks every 5 – 10 days, give or take.
What I did this time:
1st Day: I simply told her to rotate while she was sitting there to one side, then the other. Then I asked which was easier…and she replied that they both were bad…then I told her my bastardized TMR rules that one side wasn’t as bad…she agreed then began my “speed” or “bastardized” version of TMR which was to do 3 reps of 15 seconds to the easy side. She did. She repeated to the “bad” side, it was better. I asked her to stand. She did and was surprised it didn’t bother her as bad. I then had her bend forward/backwards. As she came back up her eyes bugged out…but not in a bad way. She was surprised she could move like that after a couple of movements. I asked her if therapy was easier than she thought and she said yes… “I thought I’d be lifting weights or something hard.” Then I had her do the seated arm raises. Again she was surprised, pleasantly I might add. She went from touching the tops of her thighs to her shins with 2 exercises in less than 5 minutes. Also had full ROM in the neck as well. She was now “sore but not in pain”. And she went home with 2 exercises. By the way we hired a new therapist and it was his second day here and his eyes bugged out too. He’d been out of school about 6-7 years and hadn’t seen anything like it.
What happened:
I saw her for 4 visits w/in 9 days. She did the above 2 exercises and I threw in a couple of core/stability/ab junk. Day 4 she was pain free and had full ROM. She had some morning stiffness occasionally during the 9 days. I saw her more often than I usually would because she was to see her doc earlier that most docs.
What I got:
70 y/o male. Retired ex coach, plays golf 2 x/week. Pain for over a year and a half. Right low back/buttock/leg pain to the heel. Increased symptoms with sitting, standing, walking, bending forward/backward, with golf, difficulty sleeping. Pain constant at a 5 and a “10 after playing golf”. Can’t line up his putts or squat down.
What I found:
ROM- Lumbar flex: -15%, ext: -25%, sb/rot: -25%(B) Strength- Gait-
Tests- Right lumbar/SI dysfunction
My evaluation…well you read about it above.
What I would usually do:
Same as above. Fix the lumbar/SI stuff with manual/ex and give a home ex program. At the end of the treatment the patient would feel better but not 100%. See them every 5 – 10 days, give or take.
What I did this time:
Two exercises…yep the seated rotations and the seated arm raises. Yep…Tom is part of my home exercises.
What happened:
I saw him for 3 visits w/in 13 days. The last visit he was pain free. He occasionally felt his right hamstring “get tight”. He shot a 77 the day before his last visit…the best he’s played in almost 2 years. He can also squat down to line up his putt.
By the way..I also have a patient who is a surgical instrument rep. She's in surgery just about every day. Anyway she was a mess about 2 weeks ago. I mean low back, hip, feet...essentially waist down for about a year and getting worse the past 6 months. Her 5th visit was today. She's amazed. Some about my hands and a lot about TMR. Her only complaint today was that when she crossed her left leg over her right it bothered her left lateral hip. Tried the opposite movement and it helped but not enough for the effort...then I remembered the little ankle thing to the outside (its in the manual) lo and behold, 2 reps on the opposite side..and she could cross the legs w/o problems.
I thought what I did was cool but now it's Iceberg!
Hi gang!
So I have this guy (82 y/o male) that had a cervical lam on 12/18/09. Essentially doing better. Today was the 4th time I have seen him. His neck range is pretty good. He has some stiffness in the left shoulder but not much. Prior to surgery he was having symptoms (B).
Anyway today he says he feels strange any time he writes. Says the right index finger and thumb weren't working well together. They were indeed a little weak. So I have him write something on a piece of paper. He chose to write in cursive and the same phrase printing.
I had him just pinch the opposite (or easy side) for 3 reps of 15 seconds. He tried the writing again and said that it felt better and he had more control over the fingers.
So by now you folks know he will get better overall...the interesting thing was what he wrote. I didn't look at it until he wrote the second time.
He wrote: "Use only the good side."
Wild huh?!
