Thursday Thoughts: My Current Thoughts on Repeated Motion Explanations #banthedonut

This Thursday Thoughts is really a Q&A regarding a case sent in by a frequent reader and poster to Phys I/O Forums.

Here's his email...

"What is the mechanism of relief from repeated motions? For example: just saw a pt w/ idiopathic knee pain. Pretty severe at times. Had been treating him with manual therapy, neurodynamics and progressive loading which has been slowly helping, but still has pretty irritable symptoms. On a whim today I started him on repeated extension and, a few sets of ten later, knee is nearly pain free. We'll see how much lasting relief he gets.

His back doesn't hurt at all. Could it be that there is nociception in the spine but he only feels it in the knee? Or is the spinal motion novel enough that it calms down knee pain even though the spine is not perceived as threatened?

I don't get it and don't know how to explain it to patients. Do you know why?"

Review these - lumbar manipulation for knee pain research and attempt at CPR

this study
attempt at validation - some benefitted from lumbar manipulation but no change in function or strength - not able to be replicated

Before I even get into my thoughts, I want to ask some general questions to those of you who are struggling with explanations of the effects and mechanisms behind repeated motions

what explanations do you use for mobilization/manipulation?
do you feel that grade 3-4 are generally more effective than grade 1-2 for restoration of mobility and decrease in pain perception?
think of pain as just a perception and not patellofemoral pain syndrome - it's just pain perceived in the knee

Reflect on the above as you read on

Here are my current thoughts on repeated motions as a treatment

repeated motion indications are the same as those for joint mobilization/manipulation
both have the same neurophysiologic effects

bombarding the CNS with novel, non-threatening proprioceptive information
in effect, giving awareness to a smudged area of the cortex that represents the area under threat

the further into end range you get, the more input to the CNS occurs

larger, threat free ranges are more likely to get the brain to give a green light, raising pain and movement thresholds
my analogy to patients is walking on ice - small steps due to perceived danger, versus free full and large steps when you feel safe

For the lumbar case in question

we all know that the area that is "referring pain" does not have to hurt
so "knee pain" could be referred from the lumbar spine
there is something powerful using lumbar repeated motions/mob/manipulation and improving pain and movement thresholds down the lower quarter chain
most likely due to the peripheral innervation that starts there
using the lumbar spine and loading it into end range (of a most likely limited range) restore's threat free ability to accept load

threat free load is important
if danger is perceived with load to the lumbar spine, we cannot predict where the pain will be perceived
perhaps the knee has a bit of wrinkles on the inside, plus combined with a lack of ankle mobility, hip mobility, and lumbar loading ability, the input from that area reaches a threshold that sets of an alarm in the CNS

restoring any of these things usually helps, but a combination of spinal repeated loading and the right education seems to be the more effective

Hopefully that does not seem to scattered, and I maintain that we know more about what is not happening in treated areas that what is - meaning little to no pure mechanical effects.

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...