In the last post, we introduced the concept of Bridging the Gap and discussed Segments of the Organizational System.
In this post, we’ll touch on the Pain Generator and the importance of the entire Motion Segment
In Chapter Two, the section on determining the pain generator, we identify the problem tissue. It matters whether we are dealing with a bursa or a tendon. If the client is struggling to manage a bursitis, and we attempt tool-assisted, soft-tissue work on the inflamed bursa, we might make things worse. However, if we are dealing with a tendinopathy, soft-tissue treatment might significantly help the healing process.
In another case, if the athlete has disc-originating pain, trunk flexion might exacerbate the symptoms. If we are instead looking at a stenosis, trunk flexion might improve the symptoms. Accurately identifying the problem tissue is important for us to appropriately direct our initial treatment efforts.
If you do not have examinations and assessments in your toolbox, befriend a diagnostician and share patients and clients with that person. You do not need to learn how to assess, but you do need to understand assessment and have a referral policy in place.
If no pain generator is present—such as in a patient with phantom-limb pain, chronic pain, or non-specific lower-back pain (NSLBP)—we need to use other identifiers, such as restricted range of motion, compromised movement patterns, a lack of stability, neurological influences, or biopsychosocial considerations to guide us to the area that needs our first attention. Someone who is in pain without the presence of a pain generator presents a challenging situation. There is no nocioceptive stimulation to alter: therefore, our typical pain-eliminating techniques will not work.
In the initial pain discovery, we are defining which “tissue is the issue.” In my case, I might draw from my manual therapy and differential diagnosis background to determine the problem at hand. To determine a working diagnosis for the patient in front of me, this might involve applying the skills learned in physical therapy or athletic training schools or things I mastered when studying for my certification in orthopedic manual therapy.
We might be concerned about pain and want to decrease it by using a method such as kinesiology tape. Perhaps other standard modalities will assist in pain reduction. There are many clinical interventions to choose from; your list of skills will be different, and that will guide your choices.
We need to reestablish the proper use of the entire motion segment and not just a localized injury site or source of pain. For example, if we are dealing with an elbow issue, we need to make sure the cervical spine, shoulder complex, elbow, wrist, and hand are all working together as a unit (this is the focus of Chapter Four.) We should also ensure that there has not been loss of compensatory range of motion elsewhere in the body. Through proper neuromusculoskeletal evaluation, the diagnostician will be able to determine if and where the body has compensated to protect the injured tissue. The nervous system prioritizes protection of painful tissue and adjusts movement accordingly.
I once had an athlete who had dislocated his elbow in a traumatic manner. Despite our good efforts, he ended up with a shoulder issue, including loss of motion and pain, because he was guarded and afraid to move his arm away from his body. As a result, dysfunction developed in the segment next to the injury site, which in this case was the shoulder.
We may not be able to prevent everything, but we know that the motion segments that make up and surround an injured limb or the spinal segments above and below an injury can become compromised due to fear, avoidance, and pain.
There could also be a restriction along a fascial line feeding tension upstream, downstream, or both. You can define a motion segment in many ways. You could simply consider an upper extremity, spine, or lower extremity as the motion segment, or you could think of it even broader than that, following fascial lines or kinetic chains. However, when you define the motion segment for a given patient, you must address and consider it throughout the rehabilitative process rather than just looking at a joint or tissue in isolation.
Bring the concepts of biotensegrity to mind when thinking of motion segments. Biotensegrity applies the mathematical concept of tensegrity to the human body. Tensegrity, developed by R. Buckminster Fuller between the 1920s and 1940s, is the concept that a three-dimensional structure is under constant tension with intermittent periods of compression to maintain the structure’s stability.
Biotensegrity states that in the human body, all levels—including molecular, cellular, tissue, organ, and organ systems—are operating in the same manner. Humans will maintain their general form despite gravity because of the constant state of tension with intermittent compression that occurs throughout the body. Our bodily systems, down to the molecular level, are built upon this tension. Our movement choices and postures will introduce the necessary compressive forces to allow the body to change and adapt, all while maintaining the general human form.
When we think of the body as a tensegrity system, we realize we never do movement in isolation. In order for movement in one area to occur, a resultant compression or tension must occur elsewhere to allow that to happen. This concept demonstrates a system in which nothing occurs in isolation.
While we consider these concepts and interventions, we are concerned with how the client is or is not using the entire affected limb. We might pull from manual therapy; mobilization with movement; or tool-assisted, soft-tissue work to reestablish the motion-segment function. Dry needling or cupping might be a suitable intervention choice. Alternatively, we might perhaps use fascial or visceral manipulation to deal with the affected area.
Corrective exercises learned during the Functional Movement Screen (FMS®), the Selective Functional Movement Assessment (SFMA®), or Functional Range Conditioning® (FRC) training could come in handy. Muscle activation techniques (MAT™) might also be applicable in this stage as we try to get the entire limb and motion segment functioning normally.
The options in this phase are almost limitless based on your training and area of focus.
In the next post, we’ll go more in-depth with regards to the topic of Psychomotor Control and Biopsychosocial Considerations.
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