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How to Stop Rubbing & Robbing: Sciatica Case Study

The implication is that a neuroplasticity is activated by a attention itself, not only by sensory input. Work with them to establish that new brain map.

Do we really ‘fix’ people? Or do we facilitate change?

More and more disciplines in Manual Therapy are starting to report the importance of the Patients/clients health literacy: the ability to seek, understand and utilise health information, and what is important for good health. It is as important for patients/clients to obtain and process information related to their own specific health; choices of treatment and the best choice for the individual.  This is a very challenging journey for the individual as health literacy is saturated with belief systems and poorly interpreted EBM.  It is our role to guide, encourage, educate, re-connect, identify, and lead these individuals to the relevant matters and to possibly guide them away from fundamental misconceptions they may hold.

How many patients/clients ‘give’ you their problems?

If you take on that responsibility, be prepared to fail.  When you fail, learn by your mistakes.  What a huge responsibility! And it’s not your responsibility.  Guide, educate, and help the individual re-connect with what they need to be doing/thinking on a day-to-day basis to make change.  There are 168 hours in a week, 14 hours of this time is spent preparing food and eating it, (ideally) 56 hours sleeping, 35 hours working (time taken off for eating) which leaves 63 hours per week – plenty of time to engage in your own rehabilitation.

Are you treating what you see? And treating what you feel?

CASE STUDY:

You observe restricted range of movement at the right-side hip joint on your patient/client.  The patient/client reports a feeling of tightness around the bottom area on the right side with varied intensities of sciatica running down the same-side leg.  You palpate (touch) the gluteals bilaterally (both sides) and feel a distinct ‘tightness/hardness’ on the right-side compared to the left-side.  So far you have seen and felt non-optimal movement and tone of the right-side compared to their left-side.  Soft tissue work treatment is given to the right-side gluteals, in other words you rub away (erase) the problem.

QUESTIONS:

How do you know it was the right-side gluteals that is problematic?  What if the right-side hip tension was driven by the soft tissue protecting this area? Maybe the individual has a hip pathology? Maybe the individual has symphysis pubis dysfunction (SPD)? What if the problem was being driven from the foot i.e. a dropped navicular causing a valgus knee, which would in-turn may cause the hip external rotators to grip the femoral head? If the latter is the case, you may have just increased the individuals relative risk (RR) by re-emphasised the causal mechanism: a dropped navicular.  I really don’t mean to bang-on about it, but if your hypothetical deductive reasoning is robust, then the relative risk to the individual is greatly reduced.  Here we go back to the Drama Triangle.

Are you putting your patient/client at risk of re-injury?

Consider the consequences of this if you are not adding motor control before this individual leaves your care. You’ve just released an area that may have lost the mind map to that area (i.e. be able to specifically recruit the gluteal muscles). We know the many benefits of soft tissue techniques (this is not what is under debate), but do we really expect, in this case study scenario, the patient/client to be able to immediately gain motor control just from soft tissue work? We know we are able to modify the physiology (chemistry) of soft tissues with varied ‘rubbing’ techniques, but motor control?

Soft tissue work does not create new brain-body pathway.  Soft tissue work may give us the capacity to create new brain pathways by changing tissue physiology.  But to have the patient/client experience the connection and gain motor control of that area may reduce risk and optimise the rehabilitation plan for the individual.  ‘Experience’ activates neural firing, which in turn leads to the production of proteins that in enable new connections to be made among neurons, in the process: this is called neuro plasticity (Siegel, 2012).

Neuroplasticity a nutshell is the experience for the brain means neural firing. When we have an experience clusters of neurons are activated to send electrical signals down there long lengths. The gene activation triggered by firing can create new synapses, strengthening existing ones, alter the packets of neurotransmitter that are released or the receptors that receive their messages, and even stimulate the growth of the new neurons. It can also thicken the insulating myelin sheath around connecting fibres, increasing the speed of electrical transmission. Neurons that fire together, wired together. In memory terminology, and experience becomes encoded by the firing of neurons in groups. The more often these neuro clusters, or neural net files, fire, the more likely they are to fire together in the future (Siegel, 2012).

The implication is that a neuroplasticity is activated by a attention itself, not only by sensory input. Work with them to establish that new brain map.  According to EBM massed practice of mindful activity focusing on the new neural connections being made (i.e. no distractions!) 3 sets of 10 reps (if this is too much and control is lost, reduce to 3 sets of 5 reps) preferably 3 to 4 times every day for two weeks.  The evidence suggests after two weeks of this rehabilitative practice a new brain map is formed and the individual will no longer need to ‘think’ about gaining connection and control.  Common sense must be applied with regards to progression and load.

To summarise:

“I’m a facilitator, not a fixer” Diane Lee (2016) Clinical Mentoring, Akasha, White Rock, Canada.

“The river of integration: rigidity or chaos versus harmony and flexibility” Dan Siegel, Mindsight, (2012).

NEXT WEEKS BLOG:

  • Looking at Victims, Persecutor, and Rescuer
  • Contact/non-contact injuries
  • Relative Risk (RR)
  • Dose Exposure (DE)
  • What may happen if we do not unwind the RR/DE
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