Advanced Manual Therapy 1

Why test for CAD?

Because ANY risk of artery dissection & subsequent vascular incident/stroke during end range cervical movements or mobilization is imp to ID - Very rare but serious

When to test?

1.During your initial evaluation of a patient with head or neck pain, especially important for a patient with risk factors for CAD 2.During and immediately after cervical end range rotation 3.During and immediately after treatment of any patient who reported CAD symptoms during history or physical examination 4.At subsequent visits question about S&S of CAD since last visit 5.Immediately prior and after cervical manipulation

SIJ dysfunction or not? - Test clusters

Laslett's: 1. Thigh thrust 2. Compression/gapping 3. Sacral thrust Van der Wurff's 1. Compression/Gaping 2. Thigh thurst 3. FABER 4. Gaenslen's (passive physiologic nutation/counternutation)

Clinical bottom line

Patients with cervical spine pain and 3 or more of the above findings are likely to experience moderate perceived global improvement from thoracic spine manipulation and cervical ROM exercise within 2 treatment sessions (4-8 days)

Standardized MT terminology

Complete description of a manipulative technique includes: -Rate of force application •(defines whether a mobilisation or a manipulation was performed) -Location in range of available movement -Direction of force -Target of Force: Describe the direction in which the Pt imparts the force -Relative Structural Movement (moving structure or region named first, stable segment named second, separated by the word 'on') -Patient position: Includes any premanipulative positioning of a region of the body such as being positioned in rotation or SB

C1 self MWM

For rotation left

Lumbar spine biomechanics - Sagittal plane motion

Extension Inferior facets of superior vertebrae slide downward Limited by: -facet joint approximation - spinous process approximation - tension in anterior longitudinal ligament - Total ROM 20 dg

Thoracic spine anatomy review

How many thoracic vertebrae? 12 Facet joints are in which plane? - Frontal (depending on degree of kyphosis, and segmental level) - Tip of spinous process of T7 is approximately aligned with the transverse processes of which level? -T8-9 Tip of spinous process of T7 is approximately aligned with what other bony structure? Inferior angle of scapula

Cervicogenic Headaches - No restriction in C1-C2 rotation - How is this thought to decreased headache occurrence?

Assess passive C1-2 rotation with the patient supine and neck in full flexion. (Flexion Rotation Test) - If there is NO restriction in C1-2 rotation (ie. Full 44o in each direction) Treat with: n Headache MWM and self Headache sustained MWM - The premise of these treatment techniques is headache abolition by neuromodulation.

Lumbar HVT Set up

ex. L3-L4 rotation https://www.youtube.com/watch?v=uK7mBsreJk4&feature=youtu.be (for the larger patient) https://app.physiou.com/app/cpr_ortho/j5/j5_therapy/t1012

Cross hand thrust/Thoracic PA manipulation/HVT

https://app.physiou.com/app/cpr_ortho/j3/j3_therapy/t10041

Isometric to correct anterior rotated innominate (MET)

https://app.physiou.com/app/cpr_ortho/j5/j5_cpr/pp102/c7/c7_i/c7_i_mt/g760/t1170

Intervention for Cervical ROM - C2 rotation loss

§Cervical ROM §"3 finger ROM" exercise - patient places the fingers over their manubrium, w/chin on the fingers, §Patient then rotates to one side as far as possible, then back to neutral, §Performed alternately, to both sides within pain tolerance §10 reps, 3-4 x /day §Can start with 4-5 fingers if ROM limited, decreasing fingers as Rom improves §Patient Education §Maintain usual activities within limits of pain

Why would I want to do a spinal manipulation?

•Your patient Lou Back Payne has new LBP, no radiating pain below the knee, and low fear avoidance. You treated Lou with a lumbar joint mobilizations at end range and he felt better but he did not maintain the gains between treatment sessions. YES you would want to perform

Lower cervical/upper thoracic mobilization for rotation

- I.e. bilateral transverse glide

Lumbar HVT

ex. L3-4 right rotation

Thoracic supine HVT (facet traction)

https://app.physiou.com/app/cpr_ortho/j3/j3_therapy/t7117

What is a PPIVM?

"These are movements performed by the therapist testing the available range of the client. These are movements the client can perform and resist the therapist doing if required In the periphery these are Passive ROM - Eg passive knee extension ROM

Cervical Rotation Self MWM - Which hand is the stabilizing hand? - Which hand is holding which sides of the towel? - What is the direction of the pull?

(rotation to the R)

Signs of upper cervical instability

- Arm & leg weakness - Lack of coordination bilaterally - Feeling of lump in throat - Metallic taste in mouth (CN 7) - Bilateral food & hand dysthesia

Documents for this lab:

- CSp & CTJ lab - Spine Exam Template Lab

Mid cervical spine anatomy - Orientation of C2-5 & C6-T1

- Facets are more planar - C2-5 facets are orientated obliquely 40-45dg from the transverse and frontal planes - C6-T1 facet angles reduce to approximately 10o

PhysioU Cervical manipulation activity

- How would you change this technique to deliver a manipulation (upslope/downslope)? - What biomechanical principles does this PT in this video use when setting up the C spine for the HVT? Why is this important? - How else could this lock up be achieved? - Describe a patient who would benefit from a CSp HVT? - Could you imagine a way to modify a CSp HVT if a patient has issues with closing down a facet instead of opening up? Link to PhysioU video: https://app.physiou.com/app/cpr_ortho/j1/j1_therapy/t6065

Upper cervical rotation self MWM

- To right - To improve L rotation use opposite hand placement & head rotation)

Initial concept of MWM - What would indicate suspicions of positional faults

-Minor bony positional faults, not palpable or visible on X-Ray, should be suspected in all extremity joints that are painful to move and display movement losses -Correcting the positional or movement fault reduces abnormal forces on tissue, allowing return to full pain-free function - Support in shoulder & ankle Current thinking: In my personal opinion, I find it less likely that relieving joint stiffness was the reason for decreased symptoms rather than neuromodulation of pain. As the authors stated, because of fact that rotation range increased immediately following self-SNAGs, it seems more likely that there was neuromodulation than joint stiffness relief. To be more specific, I tend to lean towards the Gate Control Theory over descending pain inhibition for the neuromodulation mechanism that I personally agree for symptom reduction. When I think of descending pain inhibition, I think of how a noxious stimulus leads to opiate release. Since the patients were instructed to do these exercises in a pain-free range, my personal opinion is that it is far less likely that a noxious stimulus was produced to cause opiate release than it was for mechanoreceptors to cause inhibition of pain (Gate Theory). Neuromodulation of pain for why MWM work & the positional fault

Upper cervical spine motion during rotation - Transition of movements occurring during rotation

0o-23o initial head rotation to the right - C1 is "cranked" to the right by the snug bony alignment of the upper C1 facets and the occipital condyles. - The lax capsular ligaments and the oblique orientation of the alar ligaments allow C2 to be unperturbed for approximately the first 20dg of head movement. - 24 dg-65 dg of head rotation (double motion phase of rotation) - The left alar ligament begins to tighten and pull the odontoid process in the same direction as C1, C1 is moving faster than C2. - The ligaments become progressively more taut pulling C2 more forcefully toward C1 and reducing the differential between C1 and C2 motion. - At approximately 65 dg of head rotation n the ligaments and capsular membranes are maximally stretched and C1 and C2 move in unison - probably also the inferior facets of the atlas and superior facets of the axis are in maximum contact - further head turning is generated by motion from C2-3 and below

Mid cervical spine biomechanics (sagittal plane motion)

1. Flexion - Inferior facets of superior vertebrae slide upward Limited by: - Posterior longitudinal ligament - Mid cervical ROM 35 dg Total craniocervical ROM 45-50 dg 2. Extension: Inferior facets of superior vertebrae slide downward - Limited by: -facet joint approximation - spinous process approximation - tension in anterior longitudinal ligament - Mid cervical ROM 70 dg - Total craniocervical ROM 85dg 3. Segmental motion - About 20 dg of sagittal plane motion at each joint between C2-3 and C6-7 - Greatest motion is at C5-6

Thoracic spine biomechanics - Sagittal plane

1. Flexion (total range 20-45o) - Inferior facets of superior vertebrae slide upward -Limited by: -Posterior longitudinal ligament 2. Extension (total range 15-20o) - Inferior facets of superior vertebrae slide downward Limited by: - facet joint approximation - spinous process approximation - tension in anterior longitudinal ligament

Indications for joint mobilization

1. To relieve pain 2. To restore normal mobility 3. To restore function 4. All of the above

What is the difference between a joint mobilization and joint manipulation?

1. Velocity 2. Point in the range

AA articulations & arthokinematics - What are the 2 joints here? - What ligament holds in place?

2 facet joints n 1 pivot joint (dens of axis, anterior arch of atlas) Primary motion = rotation Atlas twists around the dens (pivot joint) -Transverse Ligament holds the dense against the anterior arch of C1 - The articular surfaces are biconvex -As rotation occurs C1 "drops" inferiorly 2-3 mm - Rotation of atlas is coupled with slight lateral flexion to the opposite side (coupled motion is contralateral at A-A) - C1 R) rotation coupled with C1 L) side bend - Limited by tension in contralateral alar ligament, transverse ligament & capsule of A-A facet joints, muscles - AA jt provides 60% of the rotation in the C spine

Clinical bottom line for lumbar manipulation

4 or more predictor variables, 95% probability that a patient with acute LBP will experience at least 50% improvement in function (modified ODI) from lumbopelvic manipulation and exercise within 2 treatment sessions (4-8 days)

Mid cervical spine biomechanics - Rotation

4. Rotation - Occurs between transverse and frontal planes - Facets are orientated 45dg from each plane - Ipsilateral facet slides down and back, contralateral facet slides up and forward - Ipsilateral facet joint is compressed, contralateral facet joint is gapped Limited by: -Ipsilateral facet approximation -contralateral ligamentous tension -Total Mid cervical ROM 40-50 dg in each direction - Segmental ROM 8-19 dg

Thoracic technique documentation

A high velocity, small amplitude end range, posterior-to-anterior force to T4 on T3 spine in a prone position SNAG R rot C6-C7 documentation: •"a sustained, end range, R) rotation force, to L) C6 tr pr, on L) C7 tr pr, in a sitting position" with "active R) Cervical rotation to end range with overpressure" 1x6-10 reps Lumbar tehcnique: •"a high velocity, end range, left-rotational force to L5 on L4 in a left side-lying, right thoraco-lumbar rotation and lateral flexion position"

Cervical Artery Dysfunction

Abnormal blood supply to the brainstem resulting in neurovascular s/sx Vertebrobasilar artery dysfucition = same thing

PPIVM: Technique - How do we do it?

Adjacent spinous processes are palpated simultaneously and movement between them is assessed as the motion segment is passively taken through its physiologic range (flexion, extension, side bending, or rotation)

Subjective examiunation

Dizziness = most common symptoms - Question every UQ pt about dizziness, we need to find out what - Differentiate the type of dizziness, then clear the remaining D's and N's

Accessory motion testing - What 2 things are you trying to determine?

Examinatio to determine 2 things: Pain or no pain Hypomobility, normaly monility, hypermobility

Resisted hip abduction (SIJ test)

Hip positioned at full extension and 50 degrees abduction

Joint mobilizations to correct a positional fault: Lateral epicondyalgia - Does the joint need to be in OPP? - What are symptoms resultant of?

Joint DOES NOT have to be in open-packed positon...this technique works via neuromodulation Symptoms of persistent lateral epicondylalgia (tennis elbow) may result from: - tendinosis of the common extensor tendons, and/ or - from the olecrenon being too medial in the olecrenon fossa of the humerus (a positional fault). Apply small amplitude end range lateral mobilizations to the olecrenon to correct the positional fault and resolve pain.

Segmental ROM in T-spine - Upper, mid & lower

Median ROM 1. Upper T spine 4 dg flex and ext, 6 dg lat flexion, 8-9 dg rotation 2. Mid T spine 6 dg flexion and ext, 8-9 dg lat flex 3. Lower T spine 12 dg flexion and ext, 8-9 dg lat flex, 2-3 dg rot

Cervical spine lab - Examination

New additions from this course - Soft tissue assessment and mobilisation upper cervical -O-A Flexion/Extension -O-A side bending -O-A unilateral flexion -A-A rotation n Flexion Rotation Test (FRT) -C2-7 upslope and downslope (short lever and long lever) (facet joints approximately 45 dg , towards corner of eye, SB and rotation are coupled ipsilaterally)

Cervical extension MWM - Hand placement? - Is overpressure given at the end? - What part of the spine is this typically done in?

Move hands & neck together Pressure = enough to relieve the pain If upper cervical spine has bad motion, but lower c spine is problematic, ask to 'do a chin tuck

Transverse ligament

Passes posterior to the anterior arch of the atlas and the dens of the axis forming the fibrous part of the fibro-osseous ring. It attaches on each side to the medial aspect of the lateral mass of the atlas

Active SLR

Patient performs ASLR; if pain and compensatory movements noted; therapist provides compression to pelvic ring. If ASLR improves with compression, this indicates poor motor control of pelvic ring stabilizers

Inversion sprain theory & MWM distal tibfib AP glide

Perhaps the ATF ligament is not as weak as some might believe. It is quite strong, that is why avulsion fractures occur at the lateral ankle. - The ATFL is strong enough that it pulls the fibula anteriorly during an inversion sprain. - Thus, an ankle sprain might not only be a ligamentous injury but also a positional fault of the distal fibula anteriorly

CAD: International Federation of Orthopedic Manipulative PT - What does a CAD allow us to do during our exam? - What is the evidence about safety of CSp manipulations?

Provides us with a framework for cervical spine exam Used in conjunction with clinical reasoning & EBP Used for end range cervical motions, manipulations or mobilization Positive findings = contraindication to manual therapy Updates: - NSAIDs have an extremely high risk of GI bleed/death compared to cervical spine manipulation or vigorous exercise - Although HVT have increased risk, using as intervention for neck/headache related diagnoses doesn't have increased risk compared to GP visit...Suggests that those undergoing c-spine manual treatment had impending dissection. - HVT especially in mid-range positions isn't able to generate sufficient vessel stress or hemodynamic changes to explain the dissection

Cervical extension self MWM - Changes in pull of the towel with upper Csp vs lower Csp

Pull of the towel should be similar to the level Upper c-spine = more horizontal Lower c-spine: More angled

Flexion rotation Test - What is this used for? - What is a positive test?

Purpose: Determine C1-C2 limitation in rotation for cervicogenic headache diagnosis

Case example 1 - Regionalization & segmentalization

Regionalization: Differentiate movement loss between cervical & thoracic regions Segmentalization: Determine which thoracic segment has movement loss (patient sitting) Case example: Mr. Linka reports pain in the CT region with a general ache into the upper traps when looking up to gaze at the stars with his son. What is the first thing you need to assess? And how would you do it? Then you ask him to forward slump his C and T spine. You stabilize his first ribs and ask him to look up only allowing his C spine to extend. He reports a reproduction of his pain with this activity. What do you know and what do you do next? Cervical spine is the problem, MWM for c-spine extension improvement. Painfree.

Cranial cervical flexion test - Biofeedback, DNF endurance

Scoring: - Multiply the mmHg increase X the number of repetitions. Eg: Patient can perform a 4 mmHg increase (24 mmHg) for 6 reps of 10 sec. (4 X 6 = 24). Normal Score: 60 points - 10 x 10 second holds at 26mmHg - Highest possible score is 100 ... 10x10 second holds at 30 mmHg (a 10 mmHg increase from baseline) Abnormal Performance/Score: 1. Cannot raise the pressure in the Stabilizer to 26 mmHg. 2. Cannot hold the generated pressure for at least 10 sec. 3. Uses the superficial neck muscles or sudden movements.

PIP MWM - Indications - What is imp to f/u with? - How to turn this into an HEP?

Stabilize the proximal phalanx -Mobilize the middle phalanx medially or laterally (or rotate), whatever feels good - patient provides AROM & overpressure Indications: pain and/or limited ROM Take a painful joint until you find the one that eases the discomfort & increases ROM Give overpressure at the end to increase tissue length Once range has been gained in treatment always follow with exercises to maintain new range and to gain strength in new range. How to turn into HEP? While soaking hand in warm water, actively flex PIP joint and apply overpressure. - 3 x 15 sec hold/stretch, repeat 3 times a day.

CAD subjective interview

The patient's history will help you decide if CAD testing is indicated .... Some examples of historical findings suggestive of CAD and therefore warranting testing: -Fall (even seemingly low impact falls especially if wearing protective helmet that adds mass to the head), -concussion, -'worst headache of my life', -'worst neck pain of my life', -bump on head, -whiplash, -headaches, -neck pain, -5Ds 3Ns -'holding head to keep it safe on neck', -'my head feels like it is going to fall off', -Rheumatoid Arthritis, -Ankylosing Spondylitis -Down's Syndrome -most common mechanism for a non penetrating trauma injury to the VA is neck hyperextension with or without rotation or side bending (Dutton M. 2008 p 1236) -even in absence of underlying trauma cervical rotation approx 20 degrees and extension approximately 20 degrees have been shown to reduce the lumen of the VA and therefore compromise blood flow to the point of almost complete occlusion (Dutton M. 2008 p 1236)

Cranial nerves - Why do we test cranial nerves?

There location is so close to the vertebrobasilar artery MMT UFT = to test right UFT: right occiput to right shoulder, elevate acromial end of clavicle and scapula, turn face away b/c UFT originates on spinous process C7, ext occ protub, medial 1/3 sup nuchal line, and lig nuchae MMT SCM = to test right SCM: side bend right and rotate left b/c SCM is ipsilat SB and contralat rot

Risk factors/VBI questions during subjective examination - VBI insufficiency/internal carotid artery disease/trauma

VBI questions - Do you have a headache now? Neck pain now? - Do you suffer from any of the 5D's, 3N's? - Do you suffer from tinnitus? -dizziness, drop attacks (LOB but no LOC, precipitating factor usually head/neck extension), diplopia, dysphagia (CN 9/swallowing), dysphasia, nausea, numbness (CN 8)(lips/tongue---CN 5 or 11)

Side lying thoracic PPIVM/PAIVM

Why? When preparing for thoracic DOG, when can't lie prone, when pt can't tolerate seated position for segmentalization assessment Options available: PPIVM flex/ext/SB/rot, PAIVM posterior glide/AP, PAIVM rot (block the top transverse process of the inferior segment--> If pt is right side lying, blocking left TP of T6 = L rotation of T5 on T6

Alar ligament stress testing

a pair of strong rounded fibrous cords of which one arises on each side of the cranial part of the dens, passes obliquely and laterally upward, and inserts on the medial side of a condyle of the occipital bone

Practice your speed

•High velocity needs to be practiced •Go to the grocery store! •Goal: to deliver a high velocity low amplitude thrust to one spinal level!

Manual therapy treatment considerations

•How do you want to treat your patients with spinal pain? •What has helped this person in the past? •Other health care provider experiences?

Mobilization wedge

- A mobilisation wedge can be used effectively for thoracic spine mobilisation and even manipulation. - The draw back is that the therapist can not feel the joints during positioning or treatment. - Some patients like to use them at home in place of a rolled towel for self mobilisation. Tips for larger patients: https://naiomt.me/2014/12/04/supine-thoracic-manipulation-in-larger-patients/ Sitting thoracic manipulation: https://naiomt.me/2014/12/06/sitting-thoracic-manipulation/

PhysioU Upslope & Downslope videos

- How are these techniques different than the upslope/downslope techniques we just learned? - What are the similarities? - Which techniques do you feel would be most beneficial to deliver a localized joint mobilization? - Describe a patient who would benefit from an upslope joint mobilization: Limited upper cervical spine rotation (would upslope the contralateral side due to coupling pattern) - Describe a patient who would benefit from a downslope mobilization: Limited mid cervical spine side bending (would downslope the painful side due to ipsilateral coupling) Link to PhysioU videos: https://app.physiou.com/app/cpr_ortho/j1/j1_therapy/t6044 https://app.physiou.com/app/cpr_ortho/j1/j1_therapy/t6043

Precautions for joint mobilizations

- Joint effusion or inflammation - Osteoporosis - Hypermobility (pregnancy if tech. is applied to the spine) - Steroid or anticoagulant therapy - Rheumatoid arthritis (not in a state of exacerbation)

AA rotatory fixation

- Predictable relationship between C1 and C2 is depicted by three distinct regions - When C1 rotates from 0 dg to 23dg , C1 moves alone - When C1 rotates from 24dg- 65 dg , C1 and C2 move together, but C1 always moves at a faster rate, C2 being pulled by yoking ligaments (alar ligaments) - From 65 dg onward, C1 and C2 move in exact unison with a fixed, maximum separation angle of approximately 43dg, further head rotation being carried exclusively by the subaxial segments

Reps & sets for manual therapy intervention - Through range pain - End range pain

- Reassess after every 5-10 reps (this will constitute 1 set for this session) -Continue if pain &/or ROM is improved -Discontinue for the session when significant improvement has been achieved, or when improvement plateaus -4-5 minutes of mobilisation (Kisner & Colby, 2007; Maitland, 1991) -Follow with resisted isometrics, AROM, functional exercises into the newly gained range 5-10 reps immediately afterward, and every 2-3 hours that day, and 3-4 times subsequent days until next therapy session

Thoracic spine biomechanics

- Side bending and Rotation are interdependent, one cannot occur without the other - Coupling in the T Sp is inconsistent. (Sizer et al 2007)

LBP: red flag screening & referral out for further testing

- Significant trauma - Weight loss - History of cancer - Fever - Intravenous drug use -Steroid use -Patient over 50 years -Severe, unremitting night-time pain -Pain that gets worse when lying down

Thoracic manipulation for neck pain pts

- Symptoms < 30 days (strongest) - No symptoms distal to shoulder - Looking up does not aggravate symptoms -FABQPA score <12 -Diminished upper thoracic spine kyphosis (T3-5) -Cervical extension ROM < 30 dg(inclinometer) Probability of success: Less than 3 variables, predicts patients who would benefit from intervention OTHER than manipulation 4 or more variables, 93% prob of success 5 or 6 variables, 100% prob of success

Contraindications

- Systemic or localized infection, febrile - Acute circulatory condition - Malignancy -Open wound or sutures at treatment site -Recent fracture -Inappropriate end feel or evidence of joint ankylosis or hypermobility -Advanced diabetes -Rheumatoid arthritis (in state of exacerbation) -High level of pain (eg. in acute state) or high irritability -Extensive radiating pain -Any condition not fully evaluated -Positive Cervical Artery Dysfunction Testing (CAD)*

Intepretation of Exam Findings for CAD screen

-Positive subjective + Positive objective =NO manipulation or end range rotation, REFER back to physician -Negative subjective + Negative objective = HVT or ER rotation -Positive subjective + Negative Objective = Clinical judgement * -Negative subjective + Positive Objective = Clinical judgement *A report of symptoms of VBI should be given greater weight in clinical decision making than a negative test response •If an adverse event occurs, STOP, first aid, emergency assistance

What do joint mobilizations do?

-Relieve pain -Restore normal mobility* -Restore function -All of the above* *Depending on the place in the range you are treating.

Physical Examination: Cervical ROM

-Routine C Spine examination •Including physiological ROM to END RANGE with overpressure (where applicable) •Question patient for symptoms, AND observe for signs of CAD throughout examination (especially during ROM and joint accessory motion testing) -If ROM is limited by stiffness or pain the vertebrobasilar system may not be adequately compromised •Make a note of this and modify further examination and treatment accordingly -i.e. do not prescribe end range home exercises

CPR for LBP, spinal manipulation

-Symptoms < 16 days (strongest) -At least 1 hip with >35 dg IR -Hypomobility with LSP spring test -FABQW score <19 -No Symptoms distal to knee 4+ variables, definitely manipulate (95%) 3+ variables (68% prob of success), worth a trial of manipulation

Indications for use of joint manipulations

-To relieve pain -To restore normal mobility -To restore function -All of the above

MWM Background Information - What motion is the pt performing? - What are 2 critical pieces to performing MWM?

-Treatment involves sustaining the mobilisation while the patient performs the active movement that was painful, limited or stiff (the "movement") -sustaining the mobilisation throughout the entire active movement is critical, do not release the mobilisation until the joint has returned to the starting position -The technique should not be painful. -Overpressure is applied at the end of each active movement - overpressure is critical to successful treatment (with a few exceptions) -Initially, the MWM is repeated 6-10 times -On reassessment of joint function, the movement should remain improved without the mobilization - in some cases more than one set of MWMs are required to restore full function

Regionalization using provoking/alleviating tests - Is it the CSp or TSp?

1. Axial compression is painful (distraction may relieve) - Could be CSp or TSp - Differentiate by comparing with TSp compression (still painful? TSp) 2. R) Rotation CSp in neutral is painful - Could be CSp or upper TSp -Differentiate by rotating trunk & neck to the L) to end range, fix TSp at this end range, then rotate CSp to R), (still painful? CSp) 3. CSp extension is painful - Could be CSp or upper TSp -Differentiate with full C & T spine flexion (slump), fix both 1st ribs (preventing TSp extension), now slowly extend CSp (still painful? CSp)

Indications for use: PPIVM

Assess the ability of each motion segment to move through its normal ROM with respect to the segments above and below it -Make a judgment about the available motion at each intervertebral segment compared to the segments above and below -Normal (expected ROM and end feel) -Hypomobile (reduced ROM or abnormal end feel, with or without pain) - Hypermobile (excessive ROM, with or without pain)

Proximal tib fib joint PA MWM

How could you make this into a self treatment?

PPIVM: Hypomobility & hypermobility - What do these mean?

Hypomobility - Painful hypomobility suggests acute sprain of a structure related to the joint - Painfree hypomobility suggests a contracture or adhesion - Use PAIVMs to further assess joint glide and end feel to determine whether the reduced motion is due to articular or extra-articular restrictions - If hypomobility is diagnosed, PPIVMs can be used to treat the hypomobility Hypermobility - Painful hypermobility is usually instability - Use stability tests to differentiate between hypermobility and instability - If hypermobility is diagnosed, use stabilization protocols to treat - Mobilization of the segments adjacent to the hypermobile segment/s may be indicated in conjunction with segmental and/or regional stabilization

Tectorial membrane testing

Is an extension of PLL, runs from atlas to occiput, limits flexion and distraction of Occiput on atlas

C7 upslope - How do you make sure the segments above are "locked out"?

Locked up upper cervical spine to treat rotational impairment = SB to the side & rotate away contralaterally -Rotational deficit = use upsloping, typically the upper c spine (not lower) Long-lever set up (cervical spine is NOT in neutral like originally learned) 1. Side bend to the ipsilateral deficit side until you feel side bending to the segment you want to treat 2. Rotate contralaterally. 3. Rotate head in the direction with your glide. 3. Apply upslope, can compress or oscillate depending on patient preference. Should be performed in a painfree range.

Clinical implications of DNF exercises - What is the most critical component of doing these exercises? - Activation of muscles during an MVA? How to prevent?

Motor learning research tells us that repetition is critical for motor learning - We all know our most compliant patients will lie supine 2-4 times a day at best to complete any exercise! - On average the functional seated DCF exercise in this study was performed 15 times per day during the 2 weeks of the study - Enough repetitions for motor learning and behaviour change AND it is functional Clinically, even greater improvement might be expected with a combination of functional seated DCF AND formal hook lying CCFT training - There is enough support in this study for us to confidently include BOTH hook lying AND seated DCF exercises in our evidence based treatment of patients with neck pain - Data on biomechanics of whiplash injury suggest the time required to react to an impending injury and generate enough stabilising force may exceed the time of the whiplash event (Neumann, p339) p For this reason, athletes need to anticipate potentially harmful situations and contract the neck muscles BEFORE impact, the timing of muscle contraction appears as important in protecting the neck as the magnitude of contraction force (Neumann p 340)

Thoracic spine biomechanics - Transverse plane motion

Rotation (total range 35-50o) - Contralateral facet slides up, ipsilateral facet slides down - Contralateral facet joint is gapped, ipsilateral facet joint is compressed - Orientation of facets facilitates rotation Limited by: - Ipsilateral facet approximation - Contralateral ligamentous tension

Isometric to correct posterior rotation innominate

https://app.physiou.com/app/cpr_ortho/j5/j5_cpr/pp102/c7/c7_i/c7_i_te/c7_i_te_10/g33/t1365

Use a stability belt (SIJ)

https://app.physiou.com/app/cpr_ortho/j5/j5_cpr_all/c7/c7_i/c7_i_te/c7_i_te_12/g52/t1201 https://app.physiou.com/app/cpr_ortho/j5/j5_cpr_all/c7/c7_i/c7_i_m/t1372

SIJ mobilization - Posterior rotation of R ilium

https://app.physiou.com/app/cpr_ortho/j5/j5_therapy/t1168

SIJ MET

https://www.youtube.com/watch?v=bth_8SZp28I Seen in CE1

SIJ manipulation

https://www.youtube.com/watch?v=yotr8V-CEyI&feature=youtu.be

To deliver the HVT: 3 Steps

1.Identify the joint and the restriction by assessing end feel with accessory motion testing 2.Engage the barrier that is restricting further joint motion -here's where the skill of end feel assessment and knowledge of joint biomechanics is critical to ensure the HVT will be applied locally to the restricted joint 3.Apply the HVT to manipulate the joint (distract, translate...)

Techniques for LBP pts that satisfy CPR rules

3 techniques: 1.Supine global lumbar rotation thrust as used in CPR development study, maximum of 2 attempts per side 2.Side lying more specific lumbar rotation thrust sore side up, maximum of 2 attempts 3.Prone central PA to L4 and L5, 2x60 seconds at each level, 30 seconds between each set

How many reps/sets for Neuromodulation of pain AND Treatment soreness?

- 30 seconds to 2 minutes of mobilization (Kisner & Colby, 2007; Maitland, 1991) -Follow with resisted isometrics or AROM into the newly gained range 5-10 reps immediately afterward, and every 2-3 hours that day, and 3-4 times subsequent days until next therapy session

How many reps/sets for Through range pain AND End range pain?

- 4-5 minutes of mobilization (Kisner & Colby, 2007; Maitland, 1991) - Follow with resisted isometrics, AROM, functional exercises into the newly gained range 5-10 reps immediately afterward, and every 2-3 hours that day, and 3-4 times subsequent days until next therapy session

Treatment - TSp manipulation

- TSpine responds well to HVT to restore motion, and to manual techniques in general - Most used HVT technique is facet traction/gapping n "Thoracic DOG", a PA to the inferior partner of the motion segment by dorsal fixation and thrust from A-P, patient in supine - TSpine HVT used to treat: - TSpine dysfunctions n mid and lower cervical dysfunctions - Shoulder girdle dysfunctions - Lumbar dysfunctions - Rib dysfunctions

2 Leg rotation - What diagnosis is this most likely helpful for?

- VERY useful for radiculopathy for disc herniation

PILLS & CROCKS

-Contraindications -Repetitions ~6 -Overpressure @EOR -Communication -Knowledge -Sustained -Move Slowly -Use common Sense -Painfree -Instant result -Long -Lasting

How many reps/sets for MWM?

-If using mobilizations with active range of motion -2-3 sets x 6-10 reps, re-assess after each set -Follow up with self mobilizations with active movement at home 6-10 reps, anywhere from twice per day, to 2 hourly

MWM - What really is it?

-MWM is simply -Sustained joint mobilisation combined with Joint active movement -MWM can be applied to most any joint in the body -MWM have been made popular by Brian Mulligan of NZ

Cervical DNF interventions

1 visit to teach seated DCF exercise - Neutral lumbopelvic position - Gently "lift the base of the skull from the top of the neck" as if to lengthen the neck - Scapula position correction if needed 2 further visits within 2 week study to check performance of the exercise and compliance with exercise program HEP prescription - 10 seconds hold every 15-20 minutes of every waking hour for 2 weeks - 2 weeks chosen for this pilot study as a change in muscle behaviour can be expected in this time frame - Record exercise frequency in log book

Cervicogenic headaches - What are the 2 categories?

1. Headaches with no restriction in C1-C2 rotation (cervical flexion test) 2. Headaches with restriction of C1-C2 rotation to L or R

Joint accessory motion testing - Upslope - Downslope - Short lever - Long lever

1. Upslope: Movements of the facet joints in the mid to lower cervical spine that occur during contra- lateral rotation or contra- lateral side bending (think arthokinematics) 2. Downslope: Movements of the facet joints in the mid to lower cervical spine that occur during ipsi- lateral side-bending, rotation and extension (think arthokinematics) 3. Short lever: These are testing movements or mobilizations that are in direct contact with the segments to be moved. The sensing finger and motive hand will create the movement together. They will generate accessory movement in the joint. They are useful for testing, acute spines and elderly spines, that have limited physiological motion 4. Long lever: These are testing and treating movements that utilise locking of two or more cervical segments to create a lever. These are often helpful when assessing physiological movements and make the movement more specific to a particular level. They are useful for mobile necks, younger patients and when the contact points on the neck are tender or acute. Locking of the cervical joints is achieved by combinations of rotation and side bending of the spine.

Mid cervical spine biomechanics - Frontal plane motion (side bending)

5. Side bending - Occurs between transverse and frontal planes - Facets are orientated 45 dg from each plane - Ipsilateral facet slides down and back, contralateral facet slides up and forward - Ipsilateral facet joint is compressed, contralateral facet joint is gapped Limited by: -Ipsilateral facet approximation - contralateral ligamentous tension - Total Mid cervical ROM no norms - Segmental ROM no norms (more side bend at lower segments)

Article: Can a functional postural exercise improve performance in the cranio-cervical flexion test?

A pilot study, n=20 patients with persistent neck pain and poor performance on CCFT - Investigated effects of training the DCF in functional position (neutral spine sitting with added neck lengthening) - This neck lengthening maneuver strongly activates the longus colli - Exercise effect was assessed by changes (pre and post training) in SCM EMG activity during CCFT

Results of intervention

After 2 weeks of daily seated DCF exercise - SCM EMG activity in CCFT was significantly reduced at 1st and 3rd stages of CCFT - SCM EMG activity at 2nd, 4th and 5th stages was reduced but did not reach statistical significance - These findings infer an increase in DCF activity - Earlier invasive studies (Fountain et al 1966! In Beer et al 2012) have shown this neck lengthening exercise strongly activates longus colli - Jull et al 2009 (In Beer et al 2012) saw reduced SCM activity and increased in DCF activity when training the DCF in supine using CCFT - This pilot study suggests a functional seated DCF exercise can improve DCF recruitment in the CCFT

Cervicogenic headaches with restricited C1-C2 rotation - Assessment & Intervention? - How many reps/sets?

Assess passive C1-2 rotation with the patient supine and neck in full flexion. (Flexion Rotation Test) - Normal rotation ROM is 44 degrees. A Positive test = 10 degree or greater loss of ROM. - If there is restriction of C1-2 rotation to left and/or right Treat with: - C1 self sustained MWM to restore loss of motion (towel edge aligned with base of nose). Usually only a few reps ( 2 reps twice a day) are required.

AA flexion/extension

Atlas acts as a spacer between occiput and axis n A-A flexion = 5 dg -Atlas pivots forward away from dens A-A extension 10o - Atlas pivots backward toward dens -Atlas backward pivot motion is limited in part by dens contacting posterior aspect of anterior arch of atlas

Mid cervical spine coupled motion - What is the purpose of coupled motion?

Coupling of rotation and side bending increases the available ROM and softens the end feel - Coupling of motion occurs because of the orientation of facet articulations - Non coupled motion has less ROM and a firmer end feel = Used for 'locking' pre-positioning in joint accessory motion and HVT Side bending & rotation are interdependent, one cannot occur without the other due to the orientation of the articular facets - Rotation and side bending are coupled ipsilaterally in mid cervical spine - Rotation:side bending ratio 2:3 at C2 - Rotation:side bending ratio 1:7.5 at C7

Deep neck flexor training

Deep neck flexors are: 1. Upper cervical spine - rectus capitus anterior - rectus capitus lateralis 2. Lower cervical spine - longus capitus -longus colli Extrinsic neck flexors are: - sternocleidomastoid - anterior and middle scalene *often the extrinsic muscles are the dominant muscle group during cervical flexion causing anterior translation of the head and cervical spine with diminished anterior sagittal plane rotation (true cervical spine flexion)* Retraining of the Deep Neck Flexors helps normalize the forces in the cervical spine and restore pain-free function.

Lumbar spine biomechanics - Sagittal plane motion

Flexion Inferior facets of superior vertebrae slide upward Limited by: - Posterior longitudinal ligament - Joint capsule - Total ROM 50 dg - Avg of 10 dg at each level with L4-5 the most mobile (13dg) - Flexion compresses the anterior disc and increases tension on posterior aspect of disc - Avg 3 dg ext at each level with L1/2 and L5 S1 most mobile with 5 dg ea.

OA arthokinematics - What is the primary motion? - What ligament limits OA flexion & extension? - Coupling here?

Flexion/extension = primary motion 1. OA flexion: Convex occipital condyles slide posteriorly on concave superior articular facets (lateral masses) of atlas -Flexion (15-18 dg) and 5 mm translation limited by tectorial membrane - Same motion as retraction 2. OA extension - Convex occipital condyles slide anteriorly on concave superior articular facets of atlas -Extension (15-18 dg) and 5 mm translation limited by anterior longitudinal ligament -Same motion as protraction 3. Side bending -About 2 dg in each direction - OA side bend is contralaterally coupled with rotation at OA and AA due to atlanto-occipital ligamentous tension & shape of the OA and AA facets - (R) side bend occiput occurs with translation of the occiptal condyles to the left and slight (L) rotation of occiput and atlas

Maitland grading - Forces

Grade I and IV usually rapid oscillations Grade II and III are smooth, regular oscillations at 2 or 3 per second for 1 or 2 minutes K&C, 2007 Low amplitude high speed oscillations can be used to inhibit pain (K&C, 2007 pg 119)Slow speed oscillations to relax muscle guarding (K&C, 2007, pg 119) Alternatively, for painful joints, use sustained joint accessory motion, distraction 7-10 seconds, few seconds between, re-assess after a few cycles (K&C, 2007) Alternatively, for restricted joints, use 6+second stretch force, followed by partial release back to grade I or II, then repeat with slow intermittent stretches, 3-4 seconds between each (K&C, 2007) Kaltenborn, grades 1-3 sustained translatory glide technique

Beyond tissue resistance

High Velocity Low Amplitude Thrust Manipulation beyond tissue resistance but before anatomical limit to briefly take joint beyond the restricted range of motion Positional fault and pain -Reflexogenic effect from inhibition of alpha motor neurons causing muscle relaxation and an interruption of the 'spasm-ischemia-pain-spasm' cycle. - Neurophysiological effect increasing pain tolerance and increasing pain threshold

End of the range - How does this impact pain? -What are the physiological effects?

Low velocity, small amplitude oscillations at end point of movement into tissue resistance End range pain and restricted ROM -Stretch the barrier to joint motion -Neurophysiological effects -Possibly activate joint and muscle spindle receptors to reduce movement restriction

Reps & sets for manual therapy intervention - Neuromodulation of pain & Treatment soreness

Neuromodulation of pain Treatment soreness - Reassess after every few reps (this will constitute 1 set for this session) - Continue if pain is reduced -Discontinue for the session when significant improvement has been achieved, or when improvement plateaus -30 seconds to 2 minutes of mobilisation (Kisner & Colby, 2007; Maitland, 1991) -Follow with resisted isometrics or AROM into the newly gained range 5-10 reps immediately afterward, and every 2-3 hours that day, and 3-4 times subsequent days until next therapy session

SIJ lecture notes

Posture: Height of PSIS/ASIS, , test pain provocation, accessory motion testing (posterior or anterior rotation). If go posterior & it feels better, then treat in this direction. - Use bigger landmarks instead of assessing for small rotation with your hands SIJ stability: manipulation followed by stabilization exercises (make sure to do adduction squeeze afterwards). Make sure to log roll, 50% weight on each leg (positioning with baby), avoid legs crossed, sleeping with pillow between legs, take smaller steps, activate contralateral lattisimus for stabilization (i.e. walking stick) https://www.youtube.com/watch?v=bth_8SZp28I

How many HVT can I do?

Prepare the tissue using passive warm up or active warm up. Address soft tissue restrictions. -1-2 reps only on each joint - Follow up with AROM and therapeutic exercise. Level of irritability determines the frequency of movement for the HEP for these patients.

Rib articulations

Ribs have two articulations with the vertebrae 1. Costovertebral joints - "Typical" Ribs (~2-8) articulate with facets on the body of their thoracic vertebrae and the one above (costovertebral joints) - rib 3 articulates with bodies of T2 and T3 n 2. Costotransverse joints -"Typical" Ribs (~2-8) articulate with the transverse process of their corresponding vertebrae -Hang underneath tr pr in upper TSp - Are anterior to the tr pr in mid TSp - Ride on top of the tr pr in lower TSp - Ribs can restrict TSp motion - Altered TSp motion can influence rib motion

Lumbar spine biomechanics - Transverse plane motion

Rotation (10-15 dg total) - 2 dg at each segment L1-L5 - 5 dg at L5-S1 due to less sagittal oreintation of facet jts -Contralateral facet slides up, ipsilateral facet slides down - Contralateral facet is compressed, ipsilateral facet is gapped Limited by: -Contralateral facet approximation -Ipsilateral ligamentous tension -Intervertebral disc due to oblique orientation of the collagen in the annulus

AA coupled motion - What motion tightens the alar ligaments?

Rotation and side bending tighten the contralateral alar ligament - Flexion tightens both alar ligaments - The test for alar ligaments is a "test of immediacy" 1. Palpate the tr pr of C2 2. If tr pr of C2 does not begin to move as soon as the head begins to rotate, laxity of the alar ligament should be suspected 3. To confirm that the alar ligament is in tact, maintain the degree of rotation at which C2 begins to move, then add contralateral side bending (to slacken alar ligament), further occiput/C1 rotation should now be available

Notes from class - Cervical upsloping: What deficit is this mostly used for? - Cervical downsloping: What deficit is this mostly used for?

SB to the side & rotate away contralaterally to "lock out" the upper cervical spine. Rotational deficit = upsloping, upper c spine Side bending issues more mid cervical spine, would want to downslope - To facilitate right side bending: rotate left until feel spine lock up, side bend maximally, apply downslope. Add compression/oscillation if pain-free. Manipulation: Lateral glide set up? Compresses one side, gaps the other.---this technique uses lateral glide instead of SB/contralateral rotation to lock out the joint. Not at end range = safe (end range for the joint were trying to treat instead of all of the other joints). Thoracic vs cervical spine. If pain with rotation R. Rotate thoracic spine L and rotate R. If still have sx, then has to be cervical Sx

Upper thoracic extension mobilization

Seated

How do you find out which segment is the painful one?

Segmentalization using provoking/alleviating testing (in sitting): (Regionalisation testing has implicated the CT junction) -R) rotation into pain, then back off "just a bit" -Then test segmentally from below to avoid irritating segments prior to testing them - Fix T5 (thumb on Left side of sp pr) - Move T4 into R) rotation (thumb on right side of sp pr) -By default T3 will slightly rotate L) -Move up the spine until pain is provoked, this is the dysfunctional segment -Confirm by performing a L) rotation to same segment while head/neck is rotated into pain (pain should be alleviated)

Thoracic spine biomechanics - Frontal plane motion

Side bending (total range 25-45o) - Contralateral facet slides up, while ipsilateral facet slides down Limited by: - Ipsilateral facet approximation - Contralateral ligamentous tension

Lumbar spine biomechanics - Frontal plane motion

Side bending (total range 30 dg to each side) -Contralateral facet slides up, while ipsilateral facet slides down ~ 6 dg side flex at each level except L5/S1 only 3 dg Limited by: - Ipsilateral facet approximation - Contralateral ligamentous tension

Lumbar spine biomechanics - Coupled motion inconsistencies

Side bending and Rotation are interdependent, one cannot occur without the other - Pure rotation or side bending is minimal in LSP - Coupling of rotation and side bending increases the available ROM and softens the end feel - Non coupled motion has less ROM and a firmer end feel (used for 'locking' pre-positioning in HVT) - Possible Coupled motion in Lspine per HVT theory: 1. Ipsilateral rotation and side bending (when spine is in flexion) facets are not approximated, more rotation less side bend 2. Contralateral rotation and side bending (when spine is in extension) driven by facet approximation, more side bend less rotation, a lot of variability in literature

C2-C7 downslope

Side bending issues more mid cervical spine, would want to downslope - To facilitate right side bending: rotate left until feel spine lock up, side bend maximally, apply downslope. Add compression/oscillation if pain-free (similar to rotation long-lever set-up)

RESEARCH: MWM & exercise, corticosteriod injection or wait & see

Single blind randomised controlled trial - 198 subjects with dx of tennis elbow 6 wks minimum duration - Interventions compared 8 therapy sessions (MWM) and exercise, corticosteroid injections (1 or 2), or wait and see - Outcome measures: global improvement, grip force, severity rating at baseline, 6 wks, 52 wks - RESULTS: corticosteroid injections better at 6 wks but 72% recurrence rates (47/65 successes regressed) and poorer long term outcomes compared to therapy. - Therapy was better than wait and see at 6 wks and better than injections after 6 wks for all outcome measures and only had 8% recurrence - Wait and see had 9% (6/67) recurrence. The therapy group also sought less additional treatments than the other 2 groups.

Case example 2 - Regionalization & segmentalization

Small group practice with the following case: Mr. Linka reports pain in the CT region with a general ache into the upper traps when looking over his right shoulder to reverse his car out of the driveway. What is the first thing you need to assess? And how would you do it? Then you ask him to fully rotate his c and t spine to the left and then you ask him to rotate his C spine to the right. He reports no pain with this activity. What does this tell you and what do you assess next? Thoracic spine is the problem. Manipulation or mobilization of the particular region. Painfree.

Cognitive functional approach

The cognitive functional approach involves: - addressing negative beliefs and fear regarding pain and MRI findings - Patient centered education - Coping strategies' for pain - Hope for change - goal oriented behavioral change re physical activity, pacing, diet, sleep, stress - Identify maladaptive mvts and pain behaviors MSI - Targeted strengthen and conditioning

AA Passive motion assessment - What test is a more accurate for detecting the true PROM of AA ?

Why a maximum of 20o A-A accessory rotation when we learn that PROM of A-A is 44o in FRT? PPIVM and PAIVM tests are taught - Physiologic motion tested using FRT Limitations: 1. Assumes that at full neck flexion (chin to chest) the mid to lower cervical spine is "locked up" using ligamentous tension. This may not always be the case. 2. Some of the rotation may be coming from below C1-2 in the FRT 3. Not likely a problem in patients with asymmetry of motion 4. But false negative findings may occur in patients with symmetric lesions of C1-2 Accessory motion testing (supine or sitting), fix C2, rotate head and C1 to assess for no greater than 20 dg of rotation (some texts, including Dutton, say no rotation or side bending should occur if C2 is firmly fixed) - Gives a better localisation of motion to C1-2 - Test in O-A flexion, O-A neutral and O-A extension to account for wide variability in facet shape and orientation of alar ligament fibres

Interventions: lumbopelvic manipulation, exercise, patient education

•1-2 sessions over 4-8 days, sessions included: 1.Lumbopelvic manipulation -Lumbopelvic rotation HVT •If cavitation is heard or felt, proceed to therapeutic exercise •If no cavitation on 1st attempt, reposition and repeat, if no cavitation on 2nd attempt, treat opposite side a maximum of 2 attempts per side 2.Therapeutic exercise -Supine pelvic tilt home exercise program •(10 reps, 3-4 x /day) 3.Patient education -Instruction to maintain usual activity levels within pain limits Side to be manipulated determined with algorithm: 1st side of +ve standing flexion test > If standing flexion test was -ve > 2nd choice is side of tenderness during palpation of sacral sulcus > If neither side was tender > 3rd choice is side reported by patient to be more symptomatic > If patient unable to identify a more symptomatic side, therapist flipped a coin! Terminology for HVT: high velocity, low amplitude, mid to end range, posterior/inferior directed thrust to the ASIS, on the lumbar spine, in supine, low lumbar spine right side bend & left rotation"

Why is positioning so important?

•A localized treatment is more effective and safer! • •A generalized treatment is less effective (this is true of any treatment) and you don't want to move a hypermobile segment.

Vestibular vs. VBI

•Add trunk rotation to differentiate VBI from vestibular dysfunction if dizziness is provoked by cervical rotation -Sustained 10 seconds (assesses for symptoms provoked by the end range position) -5 quick rotations (assesses for symptoms provoked by cervical movement)

CAD subjective interview

•Based on information from patient history, you the PT need to decide: -Are there any precautions to physical therapy ? -Are there any contraindications to physical therapy ? -What physical tests need to be included in the examination of this patient ? -What is the priority for these tests for this patient ? -Do the physical tests need to be adapted for this patient?

CAD physical exam

•Blood pressure and palpation of the carotid artery •Cranial Nerve testing •Upper Cervical Ligamentous Stress testing -Transverse ligament -Alar ligaments -Tectorial membrane •AROM, sustained rotation 10 sec. •Pre-manipulation or Pre-mobilisation or Pre-treatment position

Cervical manipulation - When is it time to switch from cervical mobilization to manipulation?

•Cervical manipulation is beyond the scope of entry level training at UVM. The use of HVT techniques in the cervical spine is gaining support in the Manual Therapy literature. •However, the use of accessory joint mobilisation is included in entry level training and the effectiveness in the treatment of mechanical neck pain is supported in the literature. pAPA recommends that: Cervical mobilisation be used initially with its effects assessed over 24 hours or more prior to use of cervical manipulation

Risk factors for upper cervical instability

•History of trauma •Throat infection •Congenital collagenous compromise (eg. Down's Syndrome) •Inflammatory arthritis (eg. Rheumatoid) •Recent neck/head/dental surgery or hair appointment

CAD Physical Exam: Blood pressure & carotid artery palpation

•Hypertension is a risk factor for carotid and vertebral artery disease. •Acute elevation in BP can result from acute arterial trauma, and can be an early symptom of TIA or CVA. •Carotid palpation is conventionally used as part of a clinical work-up for CAD. Assess for: -Asymmetry -Pulsatile expandable mass

CAD Physical Exam - For patients with positive VBI subjective questions, what tests are safe to perform?

•If reported symptoms are clearly indicative of VBI &/or CAD: -NO provocative testing •Ok to test: BP, carotid palpation, cranial nerve exam, transverse ligament, alar ligaments, tectorial membrane •But these may not always be necessary -Refer for further evaluation prior to treatment

Lifestyle factors & LBP

•Lifestyle Factors: that increase risk of persistent LBP include... -Smoking, sedentary behaviors, obesity, sleep deficits, chronic stress - A cognitive negative LBP belief and fear of movement (are more predictive than pain intensity levels) - Catastrophizing behaviors

Middle of the range - How does this impact pain? -What are the physiological effects?

•Low velocity, large amplitude oscillations in the middle of the available range of movement •Treatment soreness and through range pain -Some hydrodynamic effect (improved joint lubrication and circulation in joint and nearby tissues) -Possibly activate joint and skin mechanoreceptors - Neurophysiological effects

Beginning of the range - How does this impact pain? -What are the physiological effects?

•Low velocity, small amplitude oscillations at beginning of movement within resistance free range •Neuromodulation of pain (Gate control theory) - No direct mechanical effect on joint restriction - Some hydrodynamic effect (improved joint lubrication and circulation in joint and nearby tissues) - Possibly activate joint and skin mechanoreceptors

CAD physical examination

•MINIMUM AROM testing for CAD Screen •Sustained (10 seconds) end range cervical rotation left and right •Examine for nystagmus, question 5Ds, 3Ns etc during and after end range rotation (10 seconds to assess for latent response) •STOP if clear S&S of VBI are provoked -Any position or movement reported by the patient to provoke symptoms

What does PT history say about manipulation?

•Mary McMillan, 1st president of APTA (founded 1921) •The four branches of physiotherapy: "namely-manipulation to muscle and joint, therapeutic exercise,... electrotherapy, and hydrotherapy." •Stanley Paris -Spinal Lesion, 1965 -Educated PT's in U.S. in manual therapy -Founding member of AAOMPT and first president of the Orthopaedic Section -Founder of University of St. Augustine •Maitland, Kaltenborn, and Paris established long term Manual Therapy education programs for PTs in the USA and abroad

Terminology in manual PT

•Mobilisation, Manipulation and Manual Therapy -Historically used interchangeably as synonyms (which they are not), and therefore grouped together in analysis of methodology and results -"If we do not clearly define and clarify these terms, then we frankly will hinder our professional growth." Mintken et al, JOSPT 2010 -"Lack of precision in terminology not only prevents us from accurately interpreting and applying research results in clinical practice, it sends confusing messages to referral sources and patients." Mintken et al, JOSPT 2010

Informed consent for CAD

•Obtain informed consent prior to any cervical procedure involving end range rotation on each and every time the procedure is performed, even if the same procedure is repeated

Why do spinal manipulations make our pts feel better?

•Pain relief (often immediate) -Possibly •Psychological •Freeing trapped mensicoid or disc fragment •Mechanical disruption of intra-articular adhesions •Correction of a joint positional fault •Neurophysiological effect: ascending and descending pain inhibition •Reflexogenic effect: muscle relaxation •Temporary hypermobility of the joint that restores normal joint play •HVT may result in 'cavitations' (sudden release of synovial gas) -Takes time (20-30 mins) for the synovial joint to reabsorb the gas ... hence the 'latent period' when joints can not be 're-popped'

Talking about LBP - Importance of imaging - Pathoanatomical education to pts? - Which factor is most predictive of recurrent LBP?

•Pathoanatomical considerations are not that important •Depression is more predictive of future LBP than MRI findings! •Early MRI of minor back strains results in poorer prognosis, more sick leave, and greater risk of surgery!

Thoracic HVT for neck pain: Intervention

•Patients treated for 2 sessions over 4-8 days •Manipulation - 3 techniques repeated twice each session •Seated distraction -"high velocity low amplitude, mid to end range, posterior-to-anterior thrust, to the mid thoracic spine on the lower thoracic spine, in a sitting position" •Supine upper t-spine (T1-4) -"high velocity low amplitude, mid to end range, anterior-to-posterior thrust, to the sternum and upper thoracic spine on the mid thoracic spine, in a supine position" •Mid t-spine manipulation (T5-8) -"high velocity low amplitude, mid to end range, anterior-to-posterior thrust, to the sternum and upper thoracic spine on the mid thoracic spine, in a supine position"

Chronic LBP & physical factors - People wither persistent LBP have....

•Physical Factors: People with persistent LBP... -have an inability to relax the back muscles -have altered movements behaviors and patterns -These altered movement patterns are associated with CNS changes reflecting an altered body schema. (central sensitization)

How do spinal manipulations make our pts feel better?

•Possible reflexogenic effect: •Manipulation elicits a stretch reflex in the joint (mechanoreceptors or muscle spindles) that leads to an inhibition of the alpha motor neurons causing muscle relaxation breaking the 'spasm-ischemia-pain-spasm' cycle. •Possible neurophysiological effect •Manipulation may cause descending pain inhibition allowing for greater muscle relaxation •Manipulation reduces input from receptive nerve endings reducing the inflow of sensory information to the CNS, ascending pain inhibition. •Manipulation increases pain tolerance and increases pain thresholds

Why does manipulation work?

•Possible reflexogenic effect: •Manipulation elicits a stretch reflex in the joint (mechanoreceptors or muscle spindles) that leads to an inhibition of the alpha motor neurons causing muscle relaxation breaking the 'spasm-ischemia-pain-spasm' cycle. •Possible neurophysiological effect •Manipulation may cause descending pain inhibition allowing for greater muscle relaxation •Manipulation reduces input from receptive nerve endings reducing the inflow of sensory information to the CNS, ascending pain inhibition. •Manipulation increases pain tolerance and increases pain thresholds

How to implement MT into your practice

•Step 1: Thorough evaluation •Step 2: Determine if joint mobs or HVTs are indicated. -Remember to Check for precautions and contraindication •Step 3 Explain treatment plan to the patient •Step 4: Obtain consent •Step 5: Prepare the tissues (active or passive warm up) •Step 6: Address any soft tissue restrictions in the area •Step 7: Carefully set up and deliver a localize mobilization or manipulation •Step 8: Correct deficits in posture, strength and muscle length •Step 9: Correct faulty movement patterns and functional deficits •Step 10: Detailed home exercise program

Risk factors - VBI insufficiency/internal carotid artery disease/trauma

•Trauma to cervical spine (large or small) •history of migraine type headaches, •hypertension, •hypercholesterolemia, • cardiac disease, • history of CVA, •history of TIA, •Diabetes, •anticoagulant therapy, • long term steroids, •history of smoking, •recent infection, •immediately post partum.

Irritability

•Why might a patient with higher irritability benefit from spinal manipulation over spinal mobilization? - Targets neuromodulation/reflexogenic inhibition rather than short term pain reduction (increases pain tolerance)

Positioning

•You need to lock up the joint above and lock the joint below so that only the segment you want to mobilize has slack in the joint capsule and is able to move when the HVT is applied. •Lock = to position the joint in a closed pack position with very little slack in the joint capsule, ie joint is stable and unlikely to move.