Massage & Bodywork

JANUARY | FEBRUARY 2020

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Ta k e 5 a n d t r y t h e A B M P F i v e - M i n u t e M u s c l e s a t w w w. a b m p . c o m / f i v e - m i n u t e - m u s c l e s . 95 instability, people have the sense of disease, discomfort, and instability. So, it's a perceptual feeling rather than a true instability. What he also showed was [that] people have more muscle activity when [irritation is] happening, so the joint is definitely stabilized and stiffer. So, we needed a rethink, [which] we had known for a while. His is just one piece of the [many] puzzles that support that [observation]. TL: So, rethinking instability as a sensation, as opposed to a movement or muscular dysfunction. GL: Yeah. We don't have the vocabulary to describe when something just feels wrong and off. Therapists tell us, "It's unstable," and then people reconceptualize that and say, "Oh, that's what instability feels like." [Really], it just feels wrong or it feels irritated—it just doesn't feel good. I'm sure you have patients or clients who say, "I feel really tight in my hamstrings." Of course, you test their hamstrings and they have great flexibility, and they're not tight at all. But we don't have the language to describe tightness or instability. We also see it in the knee. There's a paper that came out just a few months ago, in the Journal of Orthopaedic and Sports Physical Therapy, where people with knee osteoarthritis have a sense of instability in their knee. You go and measure the actual ligamentous stability and laxity, and [the measurements don't] correlate with the feeling. 4 But what does correlate with the feeling of instability is pain and weakness. There are a lot of studies out like that right now. TL: Fascinating. So, what causes [that] feeling? GL: This is what sucks. We don't know why we feel that way. And, what's difficult in our profession, especially working with patients, is it's a much easier explanation to tell someone they're unstable or their joint is stuck, and then give them a manipulation or a massage or some manual therapy, [and] then the exercise to reinforce that. So, the difficulty we're having now is how do we give people an accurate explanation for this sense of feeling off? To Learn More Preparation, Differentiation, and Integration • Greg Lehman's Recovery Strategies book, written for both clients and practitioners, can be downloaded (free) at www.greglehman.ca. • To read the full conversation with Greg Lehman and Til Luchau, go to a-t.tv/greglehman2019. The sacroiliac joint. UP-SLIPS, ROTATIONS, AND TORSIONS TL: Well, the conventional explanations are positional. You have an up-slip, you have a down-slip, your sacrum is out, you have a rotation, etc., and those are thought to make the joints sensitive. What do you think? GL: When I taught at the chiro school, we were not really teaching motion palpation. We acknowledged it historically and it was done in the curriculum, but at the same time, we were reading papers saying there's only a few millimeters of motion in the SI joint. The rotation is fractions of a degree. That'd be like the Tullberg study, which is, gosh, 20 years old now. 5 You can't move it out of position. You can't move it into position. And our test of up-slip and down-slip and torsion, those are all not reliable, meaning people can't agree. If you can't agree, they're not valid. So, we just stopped saying that. But at the same time, and again this is the thrust of the paper, no one is saying that the SI joint is not sensitive, or that it may not be a source of nociception; it can be irritated. It's a biological signal that might be contributing to people's sense of pain. We're not saying it's all in the head, we're just saying it's not because of some positional or movement flaw. But in the same vein, we're also not saying, "Don't do manual therapy," or "Don't do exercise," or "Don't manipulate." My master's was in manipulation, and the conclusion was you can keep manipulating for pain relief. [ Just don't]

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