This past month I had the pleasure of taking a University of St. Augustine continuing education course with instructor Larry Yack. The course went over spinal evaluation and manipulation (skilled passive movement of a joint). There was a tremendous amount of useful information and techniques. Here’s some random notes.
Random Seminar Notes
◊ Don’t chase pain. Pain can be misleading. One study showed that the injection of saline solution into the interspinous ligament produced similar referred dermatomal pain patterns as disc pathologies. In other words, there are many structures that refer pain down the leg. Don’t assume where the pain is coming from. Find the mechanical impairments/dysfunction.
◊ The importance of manual contact on patients – Ectoderm = Brain and Skin.
◊ The MRI results are not the end all be all. 44% are false positive.
◊ There are many reasons to manipulate – psychological, neurophysiological, biomechanical, and chemical effects. But as a clinician the primary reason to manipulate should be because research shows that it simply improves patient outcomes.
◊ Clinical Signs of Instability – demonstration of tissue creep (inability to sit still), increase muscle tone, presence of a spinal “step” or rotation, disappearance of muscle tone, step, or rotation on prone lying, shaking/juddering/aberrant motion during forward bending, difficulty coming up from forward bending, grade 5 or 6 on passive motion palpation
◊ “First Aide” for the spine should be ice, rest to allow tissues to settle down, prone backward bending, no lifting or forward bending, and maintain lordosis – Larry Yack
◊ Assess AROM for motion restrictions. Use passive intervertebral motion (PIVM) to confirm hypothesis and increase specificity.
◊ Facet Capsular Pattern : Lumbar = SB and Rot Opposite : Cervical=SB and Rot Same. If the restriction matches the facet capsular pattern then a joint manipulation may be indicated.
◊ Axial extension (upright posture) is of paramount importance for cervical patients
◊ Consider performing exercises prior to manual interventions with chronic back patients – “don’t make them passively comfortable and then expect them to become active”
◊ Find the reason why the muscle is in a hypertonic state – spasm, hypertrophy, involuntary guarding, chemical muscle holding, or voluntary muscle guarding
◊ Aerobic exercise is great for back patients (non-acute stage). Get them active. Get them moving.
◊ It’s easy to assume it’s a disc and just give press-ups. Assess what is really driving the dysfunction/impairment. For a disc pathology look for 4 objective signs: true sensation loss (pin prick), motor weakness, SLR + < 30 degrees, and diminished or absent reflexes
◊ Assess for Pelvic Obliquity in standing AND sitting. If it resolves in sitting then the obliquity may be a result of a functional shortening further down the kinetic chain.
◊ Try to increase contact area (increased proprioceptive input) when performing manual interventions
A simple way to document AROM
Bottom Line
The S1 Spinal Evaluation & Manipulation course from University of St. Augustine was a great course and has improved my evaluation and treatment skills. Before this course I was relying on treatment based classification system (TBCS) for low back pain. While the TBCS is an effective method, it doesn’t emphasize the patients biomechanical motion restrictions or spinal arthrokinematics. With the S1 Spinal course I have gained a better understanding of the intricacies in the evaluation and treatment of the spine.
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The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.
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