1 The Joint by Joint Approach Marc Heller, DC With thanks to Mike Boyle, who coined the term With thanks to Mike Boyle, who coined the term 2.cfm 2.cfm Stability- for LB and Pelvis Stability- for LB and Pelvis Mobility- for Thoracics and Hip Mobility- for Thoracics and Hip

2 More on the joint by joint The thoracics are built for stability The thoracics are built for stability Connections to rib cage Connections to rib cage Tendency to get stiff Tendency to get stiff Neither chest breathers or belly breathers move the lower thoracics Neither chest breathers or belly breathers move the lower thoracics

3 Lumbar and Pelvis Tendencies toward excess mobility Designed as a hinge, between trunk and legs Designed as a hinge, between trunk and legs In females, designed to open for childbirth In females, designed to open for childbirth In hypermobile people In hypermobile people After injury, structures that do not heal After injury, structures that do not heal

4 The brilliance of the joint by joint approach See the big picture See the big picture Recognize what areas, in general Recognize what areas, in general Need more flexibility Need more flexibility Which need more stability Which need more stability

5 Does this mean I should not mobilize the lower back, should not release low back muscles NO, this is not a rule NO, this is not a rule It is a guide It is a guide Be more selective Be more selective Be aware of the general tendencies Be aware of the general tendencies

6 Why Low Force? What is Low Force? An attitude, just enough pressure An attitude, just enough pressure Getting more information from a lighter touch Getting more information from a lighter touch A Safer way to mobilize A Safer way to mobilize Don’t upregulate the pain receptors Don’t upregulate the pain receptors Don’t startle Don’t startle

7 Pain creates Inhibition Pain (any pain) causes Pain (any pain) causes profound inhibition of stabilizers profound inhibition of stabilizers transverse abs, multif, psoas, pelvic floor transverse abs, multif, psoas, pelvic floor And Gluteus medius and Gluteus Maximus And Gluteus medius and Gluteus Maximus Weakness and timing delay Weakness and timing delay

8 What do the stabilizers do? The stabilizers are small muscles, The stabilizers are small muscles, Connecting individual joints Connecting individual joints Centrally located in the trunk (primarily) Centrally located in the trunk (primarily) They control small motions They control small motions They have precise innervation They have precise innervation They are designed to be able to activate for longer periods. They are designed to be able to activate for longer periods.

9 Inhibition Instability Pain The vicious cycle of pain

10 Vicious cycle Pain- creates inhibition of stabilizers Pain- creates inhibition of stabilizers Inhibition allows excessive movement Inhibition allows excessive movement (Especially at weak links, pain sites) (Especially at weak links, pain sites) Excessive movement stresses weak links Excessive movement stresses weak links And creates pain And creates pain

11 Muscular Patterns- hypo Multifidi, psoas, Multifidi, psoas, (plus transverse abs, pelvic floor, deep sacral gluts) (plus transverse abs, pelvic floor, deep sacral gluts) Loss of stabilizer function Loss of stabilizer function

12 Muscular Patterns- hypo- hip Hip stabilizers that get inhibited Hip stabilizers that get inhibited In frontal plane, gluteus medius In frontal plane, gluteus medius In saggital plane, gluteus maximus In saggital plane, gluteus maximus And psoas- as both a stabilizer and as a hip flexor And psoas- as both a stabilizer and as a hip flexor

13 Muscular patterns- Hyper What happens in dysfunction and pain What happens in dysfunction and pain Hypertonic, erector spinae Hypertonic, erector spinae Bulk at T-L junction Bulk at T-L junction Hypertonic- rectus femoris and TFL Hypertonic- rectus femoris and TFL

14 Mobility vs Stability theme Thoracics and TL need more mobility Thoracics and TL need more mobility Lumbars and Pelvis need more stability Lumbars and Pelvis need more stability In LB pain, vicious cycle In LB pain, vicious cycle Of rigidity in wrong places Of rigidity in wrong places Loss of stability, excessive movement at the weak links Loss of stability, excessive movement at the weak links (but the patient experiences stiffness) (but the patient experiences stiffness)

And on we go The rest of the class goes into the details, The rest of the class goes into the details, Where and how to mobilize Where and how to mobilize How to train for basic stabilization How to train for basic stabilization Management of discogenic and SI pain Management of discogenic and SI pain How to mobilize SI and the facet joints, and decompress the disc How to mobilize SI and the facet joints, and decompress the disc How to assess and mobilize the hip joint How to assess and mobilize the hip joint