When a client presents at your clinic, reporting sudden onset (acute) pain, there is, very often in their own mind, no valid reason or cause. If they were attempting to move heavy furniture, or an automobile, then they could easily identify the event.
When the cause is not known, an analysis of the source and the severity of the damage is not simple and the therapist needs to proceed with caution, using logical steps to to determine:
(a) is this a task for a manual therapist - or should it be delegated to another, more expert clinician ?, or
(b) if you deem it prudent to proceed, try to identify which sections of the supporting structure are excessively contracted, and initiate corrective procedures.
Now and then, we see instances of acute lumbar pain, arising from the simple procedure of getting up from the seated position -perhaps after reading, or viewing TV, or working at a computer; no strenuous effort has been involved, and maybe the injured person even offers the defence " I don't understand how this could happen, I walk every day, to keep fit."
There are many possible causes of this sudden discomfort - let's discuss just one of them; many of you readers will already be familiar with this topic, and may wish to tune out at this point, but for you others :
Firstly, in the seated position, as the model is demonstrating, the ilio-femoral joint is to some degree, flexed - the lower the seat, the greater the amount of flexion.
If the ilio-femoral joint is flexed, the flexor muscles are shortened, and the extensors, ( on the opposite side of the same joint) are stretched.
If you stand up from this seated position, and you will probably do so with some haste - certainly not in "slow motion" - flexor muscles are suddenly transformed from the shortened state to the stretched; like any other tissues in the body, muscles have an admirable ability to protect themselves from perceived harm.
If, for example, your finger comes into contact with a hot surface, the reaction will be swift; if a small insect collides with your eye, again the protective measures will flash into gear. In the case of the finger, it is not just the hand that responds - often the whole arm, and even the torso, will become involved.
Any threat to your eye isn't just limited to a closing eyelid - often the head will be drawn back, as the cervical segments are rapidly extended. What determines the need for, and the speed of, and the extent of, this response ? This is not a conscious thought process - there's no time for thinking and consideration here - such luxuries are by-passed.
The automatic, (or autonomic) system - ANS- arranges all this - the selection of the appropriate muscles, and the speed of, and the extent of, the protective contractions.
So, returning to the person who has simply decided to stand upright after a period of sitting - flexor muscles are stretched - if such a stretch is interpreted by the ANS as a possible source of damage - a strain, or a tear - it may well initiate a series of contractions, all in the good cause of self protection.
As an experienced manual therapist, you can identify and examine the ilio-femoral flexors - don't overlook the psoas, (or ilio-psoas) in this task. Oh, and when the clients say that they are regular walkers, or diligent exercisers, remember that although walking is a fine way to achieve a certain amount of mobility, and see the country at the same time, give some thought to just how much the ilio-femoral flexors are really stretched during a normal, or even vigorous, walking programme - not very much, I hear some of you reply.
Bernard Scully
www.theinsideout.com.au
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