MSK Rev SK, PT Anatomy & Biomechanics: unique characteristics of the spine Cervical spine: MT, exercise Thoracic Spine: OP, MT, exercise and regional interdependence Lumbar Spine: common diagnosis, further testing, numerous exercise options, MT SIJ: Pittsburgh Rules Small group / Clinical Reasoning Vignettes: Whiplash, CLBP, Upper Quadrant complaints

Anatomy & biomechanics in 3 slides Cervical: No C1 SP Vertebral artery twists from c1 to c2 AO & AA: flex & Rot opp C-sp: flex & rot same

Anat… Thoracic Easy to palpate Rotation! Related to neck, shoulder, lumbar “any” rotational entities List:

Anat… Lumbar Not designed well for flexion…but you don’t need to avoid it in a healthy spine Pll Pl disc Lack of compression from multifidi HIp

Cervical Quebec c-sp rules Vertebral artery instability > 65 yo, extremity paresthesia, dangerous mechanism Amb?, immediate pain?, midline tender?, complex Mva? AROM rotation bilateral = or > 45 degrees Vertebral artery Cardiac precautions present? Cranial nn signs? instability

Cervical mt soft tissue: if it aint tight, don’t stretch it Upper trap, Levator, scalenes (C2 – 7 TP’s to Rib 1,2) / SCM Mob’s: as always follow up with edu & Te Open, close, OA flex or SOR

Cervical TE Acute neck pain: very little evidence Chronic neck pain: cervico-scapulothoracic and upper extremity strength training scapulothoracic and upper extremity endurance training for slight beneficial effect on pain combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied Low evidence: mindfulness, general fitness, stretching only, feedback, breathing C-SP HA & RADICULOPATHY: moderate quality evidence supports specific static-dynamic cervico-scapulothoracic strengthening/endurance exercises including pressure biofeedback Snags: low evidence Flexibility: combine with other TE, be specific and target the usual suspects Exercise for coordination, strength, endurance: strong evidence / target deep neck flexors & usual suspects Traction: combine intermittent traction with other treatment Pt education: good to encourage return to normal activity reassurance that they should get better avoid giving them a ‘diagnosis’ when FAB’s are high C-SP Mobilization: strong evidence, combine with other treatments TH-SP Mobilization: lots of evidence Centralization: ‘better’ in L-SP

Th-sp OP: BMD > 1 SD below ave / T score -1 or > Fx Contraindications Address fall prevention

MT Soft tissue: hypertonicity segmental! Mobs: Ctj Supine gap

Th-sp TE Must include te for: neck, shoulder, l-sp, hip and & rotational regions or joints posture

Th-sp Ri So much to say here… Shoulder: impingement, rtc pathology Neck: everything really Lumbar Hips, feet, upper cervical, sports, job, repetitive motion, bike, swimming, etc.

L-sp Stenosis: B pain, LE > LBP, walking & standing, better w flex, > 65 yo DDD: NORMAL Instability is now movement impairment Treat hypo areas, motion, retrain (mutifidii, transvers abs, pelvic floor) Disc: extend, no flex MM strain, sprain

L-sp te options Just too many to list… In general: Get them moving Don’t peripheralize Walk Strengthen & retrain educate

L-sP TE Centralize, Centralize, and repeat TBC: Mobilization: MT, exercise: ROM, PREs (get specific), EDU Traction: refer to Fritz Stabilization: engage TA, strengthen RA, don’t forget about PF, evidence exists for multifidii Specific Exercise: ROM (vary WB and NWB), PREs: strength v endurance or both 3 x 10 is lame consider history the category is SPECIFIC exercise, not PROTOCOL exercise, or ‘what is the machine I have here at my clinic’ exercise… Disc: wake up ritual (prone, POE, PPU), lumbar roll, AVOID flexion, APT OA: move more than usual, but not too much right away Stenosis: SKTC, seated flex, DKTC, LTR, PPT MM spasm / strain: ROM, STM, modalities, EDU

L-sp MT Lumbar gapping Remember contraindications Sore side up Flex up Rotate down Pre manip hold thrust along line of femur on pelvis Remember contraindications

Pittsburgh sij rules Doesn’t exist Massively overtreated in this area There is simply no credible evidence anywhere that this should be the first region treated, that we can palpate it, or that it moves at all in most people. If you are told you need to treat the pelvis first before doing anything else, please let me know. Even if someone has pain in the sij is likely not si pain (please help)

One INJURY YOU CAN’T Treat HE was really in charge of the worlds 5th largest economy Cal-E-Forn-E-Ah