As anyone progresses through a career, they develop certain biases for why things occur. I began my physical therapy career, I believed joint stiffness (hypomobility) was the primary dysfunction and cause of pain. I felt that grade III-V mobilizations and manipulations were the answer. This is no doubt due to my orthopedic education, which focused on Maitland’s techniques for joint mobilization. As my career has been progressed and I have treated more patients, my view has shifted to one of hypermobility or excessive motion as the primary dysfunction and cause of pain. This comes from multiple sources, but I currently feel that Shirley Sahrmann is probably the best source for understanding this idea. I recently bought her newest book and in one of the introductory chapters, she describes joint hypermobility as being caused by 3 things:
1) excessive physiological motion – you bend to far or hyperextend too much – this is obvious and these people are very easy to identify in a PT examination.
2) excessive accessory motion – your joints slide around too much – less obvious, but also pretty easy to identify in a PT examination.
3) you have excessive relative accessory motion at your painful joint – this is where everyone else falls, if they aren’t in category 1 or 2, they are definitely here, but this doesn’t appear as obvious. This might be someone who appears to just have tight quads and has back or knee pain. This is the person who has a habit of moving in one part of their body and not others.
I will be using Sahrmann’s movement impairment system tests more and more when I return to work in a hope to better diagnose and treat all of these problems. But one thing she emphasizes is that it isn’t the exercises you do for PT that will make you better, it is the change in your lifestyle and movement patterns that will make you better. If you are sitting all day at a computer in the same posture, you probably will have a problem. If you are hunched over a laptop right now, you will have a problem. It is only a question of when, not if. When a patient tells me, but I’ve been doing “it that way” (a specific activity my whole life, but it didn’t hurt until now, it is still a problem.
I also really like her idea that as physical therapists / physiotherapists, we treat the body’s “Movement System.” Everything is connected, we don’t treat joints, we look at joints to see how they contribute to movement. She also recommends going to a physical therapist on an annual basis for a movement assessment to make sure your movement system is doing well and to help guide exercise for the next year. I think it’s a great model and maybe some day I will be able to treat my patients in this way.