Spinal classification, diagnosis, Rx, Mx

Key Management Issues for all conditions

● Address key functional concerns (always a must day 1)
○ by providing advice on how to modify functional activity
■ For example, if the patient complains that back pain is preventing him
from gardening because he can’t bend his back for 1 hour. Suggest that he
sits in a low stool (do decrease loading) and take breaks every half an
hour.
○ Or advice on avoiding provocative postures
■ For example, reassuring someone with a compressive patterned back pain
to lean forward on the shopping cart while shopping (to minimize time in
Lx extension)
● Address any unhelpful beliefs if there are any (always a must day 1)
○ E.g: ‘disc has slipped’, ‘must always keep back straight’, ‘PTs are magicians who
can fix my problems with a massage’
● Provide information regarding Dx, Rx options, and prognosis + reassurance
○ Be specific here by actually writing what you would say to the patient, e.g. how
long the prognosis actually is
○ If appropriate, reassure patient that his condition is benign and that his Sxs will
get better (careful not to say ‘go away’/’disappear’)
○ Appropriate warnings for the patient
● Advice on staying active
○ What does the patient like doing? Can you modify that activity so he can do it
without too much pain?
● Monitoring symptom response

Lumbar:
● Movement impairment (hypomobility disorder)
○ Classification: Movement impairment disorder
○ Diagnosis: Right sided L5/S1 mechanical lower back pain.
○ Treatment:
- Aim = restore normal mobility
- Physiological mobilisation Rx techniques (“Go to” in Lx)
- Options: Rotation or Lateral flexion
- appropriate for both flexion & extension patterns
- Accessory mobilisation Rx techniques
 -
Better for extension/compression pattern than flexion/stretch
pattern
- Options: unilateral PA or central PA
- Unilateral PA for unilateral pain; central for bilateral
- Reduce activity of overactive muscles
- With massage= 5 minutes, muscle on stretch
- HR: active/ active assisted take to end of range, 10s contraction,
take to new range, 10s contraction, take to new range, 10s
contraction, take to new range. Passively/ muscle length.
○ Management:
- Comms: move more, change positions frequently, exercise.
- HEP w/ parameters ( think ROM column)
- Keep it simple and stick to the pictures Michelle gave us
- Advice & warnings
- Prognosis: usually 4-6/52
- If provided massage or hold relax= provide complimentary stretch
- Indicate patient position 3x60s 3x per day, 1 minute rest b/n sets

● Motor control impairment (postural/ loading disorder)

○ Classification: Motor control disorder (postural loading disorder)
○ Diagnosis: Right sided L5/S1 mechanical lower back pain.
- NOTE: 2 types: Sustained EOR loading, global co- contraction= compressive.
○ Treatment:
- Very small part! Only if can’t achieve optimal posture due to lack of
mobility
- Accessory/Physiological mobilisations for joint mobility
- Soft tissue techniques for tight muscles
- Massage or hold-relax techniques
- Taping to provide cue for optimal posture
- Neurophysiological pain relief.
○ Management:
- Comms: move more, change positions frequently, exercise.
- Address posture (usually pelvis for Lx issue)
- Use cues to assist into a neutral posture
- Use cues to get patient to relax hyperactive mms for active
extension pattern
- Home Exercise Programme:
- Dedicated exercise session for posture
- Increase hold time
 - 5- 10 mins total per session; 2x per day.
- Patient will go into ‘optimal posture’ and
hold there, coming out when he feels tired.
Accumulate 5-10 mins this way.
- Add challenges
- [examples]
- Integrate new posture into daily Fx.
- Check posture, correct if necessary and holding for approx
10s (or what pt can achieve), 3- 4x per hour.
- If relevant: stretches for tight mms and active exercise for ROM.

● Motor control impairment (movement control disorder)

○ Classification: Motor control disorder (movement control disorder)
○ Diagnosis: Right sided L5/S1 mechanical lower back pain.
○ Treatment:
- Limited role for manual therapy
- Aim is to restore mobility by correcting provocative movement patterns &
postures linked with pt’s disorder.
- 1. Ensure adequate ROM / mobility & address if necessary for
function. Retrain through range control in grade exposure, starting
in less threatening or provocative positions. Integrate into
provocative Fx tasks
- 2. Address the control of posture first; Facilitate & retrain
provcative movt & loading pattern. recall postural correction to
improve awareness and modify provocative positions. In graduated
fx’al activation.
- 3. Address control of movt; motor control retraining with
integrated into procvative movements & posture + graduated fx’al
activation.
○ Management:
- Focus on pts self-Mx & active interventions that foster independence and
self-efficacy thus integrate new posture into daily Fx.
- Education & reassurance; explanation about cause of Sx
- Prognosis: slow / gradual process
- Address any yellow flags
- Warnings, ex potential red flags
- Emphasis and advice on posture, modifications of activity, activity (ex low
impact), minimising provocative positions
- HEP; Fx’al integration (ex correcting posture) repeatedly during the day
 - Retraining at clinic becomes HEP
- Ex. hold for 10 sec (or what pt can achieve), 3-5 x per hour
- Dedicated exercise sessions - small amounts frequently
- Parameters: 5-10 min worth, 2x per day - be specific
- Give advice / warnings
- Emphasis on quality (think “get m/s working”
column) (stop short of form fatigue) & Sx control
- Teach self-monitoring & use feedback (ex mirror at
home)

● Lx spinal pain with deformity:

○ Classification: Movement impairment disorder
○ Diagnosis: Right sided L5/S1 mechanical lower back pain (presenting with a
lateral shift to the left side +/- flexion deformity).
○ Treatment
- Use active/active-assisted (repeated) movts & positioning to:
1. Correct deformity (if established that repeated movements ease Sxs; if it
worsens it, don’t do it!)
● Active, active assisted or passive if needed
− Either sustained hold vs oscillatory
− 6 to 10 reps with frequent Re‐Ax
− Active/ assisted:
● Side glide in standing: patients shoulder next to wall
etc.
− Passive Rx = Physiological mobilisation techniques in
side‐ly
● physiological LF technique (eg (L) lateral shift ‐>
treat w/ right physiological LF)
● often a more general approach would be acceptable
in early stages rather than localised to 1 segment
− Centralisation of referred pain if present – gradual process
2. Restoring Lx lordosis once neutral position achieved
● Aim to restore extension once lateral shift corrected
− Patient does active repeated or sustained extension
exercises
− Progress from unloaded to loaded
− Reps 6-10 & Re-Ax pt in standing
− If necessary, can mobilise into extension in side-lying;
● physiological techniques useful initially – LF or Ext
 ● progress to (accessory) mobilisation in prone later
○ Management
- Reassurance & explanation
- Prognosis: Good - 3-7 days but variable
- First session:
- Advice for avoidance of provocation of movts
- Analgesics if required
- Heat
- Taping
- HEP
- exercises prescribed during clinical session
- Monitoring Sx
- Warnings; key being peripheralization
- Address yellow flags

● Radiculopathy
○ Classification: Specific disorder; depending on physical examination but likely
mvmt impairment.
○ Diagnosis: S1 radiculopathy (+/- radicular pain) (likely due to disc pathology/
degenerative stenosis).
○ Treatment:
- Opening up techniques= reverse physiological lateral flexion technique
(grade 3, more general 5- 10s hold x 4-6 w/ reAx); include re-assessment
relevant to case study (AWAY FROM SYMPTOMATIC SIDE).
- Indicate; monitor neurological S and S and leg pain.
- STTs to relax overactive muscles if contributing
- Address hip mobility (e.g. tight hip flexors) to allow more movement from
hip and less from Lx + thoracic spine mobility.
○ Management:
■ Same as neurogenic claudication (see below).

● Radicular pain
○ Classification: Non-specific; depends on physical examination usually mvmt
impairment.
○ Diagnosis: Right sided L5/ S1 mechanical lower back pain with radicular pain (no
clinical signs of conduction loss)
● Neurogenic claudication
○ Classification: depends on physical examination, likely movt impairment
 ○ Diagnosis: Neurogenic claudication(due to degenerative lumbar spine stenosis).
(identify segment if you can, but usually multi-segmental)
○ Treatment:
- Physiological flexion technique (grade 3, more general 3x 45s);
include re- assessment relevant to case study
- Reverse physiological lateral flexion technique on both sides
(grade 3, more general 5- 10s hold x 4-6) w/ reAx
- AWAY FROM SYMPTOMATIC SIDE
- Indicate; monitor neurological S and S and leg pain.
- STTs to relax overactive muscles if contributing
- Address hip mobility (e.g. tight hip flexors) to allow more movement from
hip and less from Lx + thoracic spine mobility.
○ Management:
- AROM (supine flexion; bring knees to chest); ROM parameters
- ADDRESS KEY CONCERNS (from case study)
- E.g. bend forwards on shopping trolley while walking, high chair
instead of standing
- Remain active: stationary bike or walking in the pool (specific to what pt
likes).
- Refer to doctor: for NSAIDS + co-management of care
- Warning: CES + wallet card (unlikely but warn anyway).
- Prognosis: up to 3- 6 months but should see improvement within 2 weeks
- Educate about Dx; note needs to be what you would say to the patient=
time consuming t/f only if necessary.

● Lx Neural tissue mechanosensitivity:

○ Classification: Non-specific; depending on physical examination.
○ Diagnosis: R L5/ S1 mechanical lower back pain (presenting with associated
neural tissue mechanosensitivity and no clinical signs of axonal conduction loss).
○ Treatment
■ Pain of NT origin is easily aggravated and may have a latent response -
DO NOT OVERTREAT
■ Reverse physiological lateral flexion technique AWAY from painful side
● Patient position:
○ Side- lying with painful side up.
● Gentle oscillations/ holds of 5- 10 secs for 30- 60 secs
○ Initially in shortened position (progress by straightening
top leg).
○ Return to neutral if sustained hold
 ○ Cease the glide just before onset of opposing m/s activity/
pain
● Monitor: stop if limb Sx increases
● ReAx:
○ Active knee extension or hip extension movt btwn sets
○ Question resting Sxs
○ Function after 3 sets
● Management
○ HEP (only if +ve response to Rx)
■ 1-ended sliders
● Sciatic= Seated knee extension with head in neutral/ extension
○ Note if add DF= 1 ended tensioner.
● Femoral= hip extension in side-lying with head, neck, upper Tx
flexed.
■ Small, baby movements only (neutral to mid- range).
● 3x5 reps, progressing to 3x10 if response known
● 1-2 times only, progress to 3/day
■ Warning: monitor limb pain, want to avoid it
○ Advice
■ Simple measures and messages
■ Avoid postures that put the nerve on stretch (work out from case study).
■ Advice to avoid stretching on affected side (aggravates Sx)
○ Prognosis:
■ SLOW, >6 weeks for notable change .
○ Refer to GP for pain medication if needed
● See wk 7 lecture notes for treatment/ management progressions pg 19+ 20.

● Spondylolysis
○ Classification: Specific disorder
○ Diagnosis: Symptomatic spondylolysis
● Spondylolisthesis
○ Classification: Specific disorder
○ Diagnosis: (anterior mvmt of L4) Anterolisthesis of L4 on L5
● Cauda equina syndrome
○ Classification: Specific disorder
○ Diagnosis: cauda equina syndrome RED FLAG
○ What to do?
■ If at suspected stage, send to GP + CES wallet card
■ If at incomplete - complete stages, EMERGENCY DEPARTMENT
Pelvic girdle:
● NSPGPD
○ Classification: excessive force closure OR inadequate force closure
○ Diagnosis: Non-specific pelvic girdle disorder.
○ Management
■ Inadequate force closure similar to lumbar motor control impairment -
flexion pattern
● Retrain
○ optimal spino-pelvic postures and equal limb loading
○ single limb loading with optimal alignment
■ Lunges and SL squats
○ Lx-Pevic dissociation
■ E.g. APT w/out tensing Tx extensors
● Relax upper abdominal and breathing muscles
● Adjuncts: pelvic belt and taping to compress pelvis
■ Excessive force closure similar to lumbar motor control impairment -
active extension pattern
● Address yellow flags
○ E.g. SIJ is ‘out’ t/f I have to squeeze my butt all the time to
keep it in place
● Stop any ‘core stability’ exercises e.g. isolated TrA wall training
● Facilitate relaxation
○ Breathing exercises, yoga, CV exercises
○ Encourage relaxed movements, such as sitting and rolling
○ Encourage more trunk rotation during walking to ‘decrease
trunk fixation’
● Adjuncts: STTs and heat to relax hypertonic mms
○ Massage multifidus and glutes
■ Outcome measure: Pelvic Girdle Questionnaire

Cervical:
● Movement Impairment Disorders
● Classification: Movement Impairment Disorders
● Diagnosis: Left C5/6 mechanical neck pain
● Treatment
○ Physiological motion mobilisation
■ NWB
 ● Lateral flexion Long Lever (‘downslope’) in supine -
extension patterns (bcs palpating ipsilateral side).
○ C2/3-C6/7
■ WB
● Rotation - extension and flexion patterns
○ C1/2-C7/T1 or T1/T2
● SNAGs (all levels, any pattern, performed in sitting).
(Guide pg 260).
■ NWB vs WB
● WB is better than NWB in that:
○ More fxal position
○ ReAx easier
○ Patient more comfortable
○ Movement limitation accentuated in WB position
○ Accessory motion mobilisations
■ Unilateral PA in prone - if patient tolerates this
● C1-C7
■ Central PA in supine
● C2-C6 or C7
■ Note: usage depends on P/E findings, flexion/extension pattern
doesn’t matter as much in Cx vs Lx
○ STTs to relax overactive muscles
● Management
○ Simple measures and messages
○ HEP
■ Sitting rotation exercises (OP as progression) - very likely
● Because rotation is more likely to improve earlier than
lateral flexion
● Because sitting is a fxal position
● OP: apply pressure through temples, not through jaw
■ DO NOT DO EXTENSION EXERCISES

● Cervical postural control disorder +/- motor control disorder: (Commonly into E).
● Diagnosis: Left C5/6 mechanical neck pain
● Treatment:
○ Very small part! Only if can’t achieve optimal posture due to lack of
mobility
○ Accessory/Physiological mobilisations for joint mobility if required.
■ Neurophysiological pain relief
 ○ Soft tissue techniques for tight muscles (usually neck extensors).
■ Massage or hold-relax techniques
○ Address posture (usually in excessive extension)
■ Use cues to assist into a neutral posture
■ Use cues to get patients to relax hyperactive neck extensors and
engage deep neck flexors.
■ Re- assess movement to see if posture is adaptive or maladaptive.
● Management:
- Comms: move more, change positions frequently, exercise.
- Home Exercise Programme:
- Postural control:
- 5- 10 mins total per session; 2x per day.
- Patient will go into ‘optimal posture’ and hold
there, coming out when he feels tired. Accumulate
5-10 mins this way.
- Add challenges
- Such as rotation whilst maintaining neural sagittal
plane motion.
- Start in sitting; progress to 4pt, prone on elbows,
forward reclined sit.
- Through range postural control: (+ for if motor control).
- Retrain movement into extension
- Start in 4pt, prone on elbows or forward reclines sitting
(easier).
- Retrain upper Cx first- progress to mid/ low Cx ext.
- Retrain in sitting last (hardest).
- Integrate new posture into daily Fx.
- Check posture, correct if necessary and holding for approx
10s (or what pt can achieve), 3- 4x per hour.
- If relevant: stretches for tight neck extensors.
- If required DNF activation specific exercises:
- Supine or long sit

● Wry neck:
○ Classification: Movement impairment.
○ Diagnosis: Left wry neck (presenting with right lateral flexion deformity)
○ Treatment:
■ Avoid prone position - supine and side-ly is fine
 ■ Address mm spasm
● Heat
● Gentle massage
■ Unloaded passive mobilisation techniques
● Mainly looking for the neurophysiological effects of
manual therapy
● Lateral glide - away from lateral flexion deformity, but not
as important
○ Gr III, gentle, 6x10s// subjective Sxs.
● Manual traction
○ Gr III, gentle, 6x10 // subjective Sxs
● Management
○ Simple measures and messages
■ Very favorable prognosis - 3-7 days to see sig improvement
■ Nothing is damaged - mainly sensitized
○ HEP
■ Rotation in supine (NWB b/c high pain severity)
● Gentle, to left and right
● Parameters: see how many patient can manage b/c pain
might be quite high - e.g. 2x10 reps 2 times a day
○ Heat to relax hyperactive mms
● Progressions
○ Treat as a normal movement impairment disorder
● Radiculopathy
○ Classification: Specific disorder; depending on physical examination but likely
mvmt impairment.
○ Diagnosis: C7 radiculopathy (+/- radicular pain) (likely due to degenerative
stenosis/disc pathology - much more uncommon).
○ Treatment
■ Avoid lying in prone initially
■ Technique opening up the IVF
● Lateral glide technique in supine- away from side of
symptoms.
○ Gr III, gentle, 6x10s// subjective Sxs.
● Manual traction in supine
○ Not recommended for grade III NAD in first 3
months according to NICE
○ Progression: put segment into direction of movt
limitation
 ■ Addressing contributing factors
● STTs, hold-relax or heat to relax overactive mms if
appropriate
○ Note: STT of traps and Lev Scap may be in prone
so take care
● Posture of neighbouring segments
○ E.g. increased flexion of upper Tx causing
increased Cx extension, t/f also have to address
upper Tx flexion
○ Management
■ Simple measures and messages
● Prognosis: favorable, usually 4-8/52
● Surgery may need to be consider if patient doesn’t improve
over 12/52
● Monitor Sxs, if gait abnormalities - Cx spondylotic
myelopathy
■ HEP
● HEP should complement Rx techniques used
● Neccessary to instruct patient to self-monitor all Sxs during
HEP
○ If worsened: consider med review
■ Outcome measure: Patient Specific Functional Scale
● Better in this case than Neck Disability Index
● Later Intervention
○ Treat and management as if it were a non-specific movt impairment
● Cervical spondylotic myelopathy
○ Red flag
● =/> 3/5 = Babibinki, >45, gait abnormality, hoffmans, inverted supinator (refer to
pg 15 wk 6 notes).
● Cx Neural tissue mechanosensitivity:
○ Classification: Non-specific; depending on physical examination.
○ Diagnosis: R C5/6 mechanical neck pain (presenting with associated neural tissue
mechanosensitivity and no clinical signs of axonal conduction loss).
○ Treatment
■ Pain of NT origin is easily aggravated and may have a latent
response - DO NOT OVERTREAT
■ Lateral glide technique away from painful side
● Initially, NT in shortened position
 ○ I.e:: shoulder adduction with arm supported on
abdomen and elbow flexion
● Parameters: gentle oscillations/holds of 10 secs for 30-60
secs
○ Note: return to neutral if sustained holds
○ Cease the glide just before onset of opposing m/s
activity/ pain.
● Monitor: stop if limb Sx increases
● ReAx:
○ Active Cx and shoulder movt btwn sets
○ Question resting Sxs
○ Function after 3 sets
● Management
○ HEP (only if +ve response to Rx)
■ 1-ended sliders (hand supported, elbow slightly flexed, CL LF)
● Small, baby movements only (neutral to mid- range).
● 3x5 reps, progressing to 3x10 if response known
● 1-2 times only, progress to 3/day
■ Warning: monitor limb pain, want to avoid it
○ Advice
■ Simple measures and messages
■ Avoid postures involving CL LF and shoulder abduction
■ Advice to avoid stretching on affected side (aggravates Sx)
○ Prognosis:
■ SLOW, >6 weeks for notable change in shoulder ROM is sig
restriction of mvmt.
■ Symptoms improve faster if shoulder abd >90.
○ Taping to unload NT - to promote shoulder elevation and upward rotation
○ Refer to GP for pain medication if needed
● See wk 7 lecture notes for treatment/ management progressions pg 17- 19.

Upper cervical:

● Cervicogenic headache:
○ Classification: Generally a movement impairment, but possibly present as a
postural loading disorder.
○ Diagnosis: Left side C1/ 2 Cervicogenic headache.
○ Treatment:
 ■ Treat the underlying movement impairment:
● Physiological motion palpation:
○ Sitting rotation C1/2 -C7/T1 (+/- T1/2)
○ Upper cervical spine passive physiological mobilisation
treatment technique in supine – C0/1 flexion??
○ 3x 45s grade 3.
● Accessory motion palpation:
○ Unilateral C1- 7
○ Central C2- 7
■ STT:
● See muscle length positions below
● 5 minutes of massage with muscle on stretch + indicate patient
position.
■ Provide postural modification if required (reducing Tx kyphosis, retract
shoulder girdle etc.).

○ Management:
■ HEP:
● Related AROM movement for mobilisation
● Related stretch for massage.
■ Postural control practise if modified during treatment.
■ Diagnosis
■ Prognosis:
● Acute: Noticeable change in 2 weeks, largely resolved in 4- 6.
● Chronic: Could take up to 12 weeks.
■ If chronic= referral to GP for multidisciplinary management (DRUGS).

Thoracic:
● Postural loading disorders: (refer to Cx and Lx)

● Non- traumatic movement impairment:

○ Diagnosis
■ Right sided T7/8 mechanical back pain.
○ Treatment
■ Accessory: grade 3, 3x30- 60s.
● C7-T3 and ribs 1-3 (arms resting at head + physio standing at head
of bed).
○ Central PA spinous process
 ○ Unilateral PA transverse process
○ Unilateral PA ribs
○ Transverse glide spinous process (stand to side of patient).
○ Caudomedial glide rib 1 and rib 2
● T4-T10 and ribs (arms hanging by side= physio standing at side of
patient).
○ Central PA with bilateral transverse process contact
○ Unilateral PA transverse process
○ Unilateral PA ribs
○ Transverse glide spinous process
● Position alterations as needed (spine positioned into F, E, R, LF).
■ Physiological: grade 3, 3x30- 60s.
● Rotation in sitting C7/T1 (+/- T1/2)
● Rotation in side lying T2/3-T11/12
■ Snags: 3x 3-6 reps.
● Rotation in sitting
● Extension in sitting
■ STT: 5 minutes, put the muscle on length, indicate patient position.
● Trunk muscles:
○ Intercostals, QL, ES, latissimus dorsi, oblique abdominals
● Cervicothoracic muscles.
○ LS, splenius capitis, rhomboids, UTs, scaleni’s (1st/ 2nd rib
mobility).
Massage= 5 minutes, put the muscle on length, indicate patient
●
position.
● HR= ideally don't pick this for exam (painful to explain)
○ Indicate patient position
○ Indicate agonist or antagonist (then need to describe this;
where you will push, your verbal prompts etc.)
○ 5- 10s x3, take to the end of range before re- assessment
(passively).
○ Management
■ HEP:
● Accessory, physiological, snags= AROM exercise
○ 3 x 10 2x per day, 1- 2 minute rest b/n sets
● STT= stretch
○ 3x 1 minute, 2x per day, 1- 2 minute rest b/n sets
● Provide warning/ regression + progression (self- Mx).
■ Prognosis (4-6 weeks), diagnosis, address un- helpful beliefs.
● Traumatic movement impairment:
○ Diagnosis: Right sided T7/8 upper back sprain.
○ Treatment:
■ Early:
● STTs (reduce m/s spasm & decrease pain).
○ Gentle massage (may not be able to tolerate muscle on
stretch).
● Active/ assisted ROM within pain free limits (commonly rotation).
■ Later:
● Treat underlying mvmt impairment (refer to above).
○ Management:
■ Early:
● Remain active with modification if needed
● Mediations (NSAIDs)
● Prognosis (4- 6 weeks).
● AROM exercises for home
○ Use heat pack for 5 mins prior
○ Gentle (not to end of range).
■ Later:
● Mx for underlying mvmt impairment (refer to above).
● Address any contributing factors limiting resolution.
● Acute locked thoracic joint:
○ Diagnosis: Acute right sided T3/4 mechanical back pain
○ Treatment:
■ Heat and gentle massage to reduce m/s spasm + sensitivity prior to
mobilisation.
■ Mobilisation:
● Accessories may be limited (tissue sensitivity)
● Leaves physiological:
○ Only one we know = Rotation in side lying T2/3-T11/12
○ (Pt positioned in side-lying [on opposite side to
mobilisation]).
○ Start conservative= 30s + emphasise pt Qing + re-
assessment.
○ Management:
■ Prognosis:
● Minimal tissue damage= minimal inflammation= quicker to
resolve.
■ HEP:
 ● Doesn`t have to be rotation (look at the case study)
● 10x 3x 2x per day.
■ Heat, NSAIDs, keep moving, modifications if required.
● Lower Tx/ Tx- Lx junction mvmt impairment:
○ Treat like Lx mvmt impairment
■ Accessories: Unilateral/ central PA
■ Physiological: T10/ 11 = as per Lx.
● Reverse LF, LF, rotation.
○ Prognosis= can be slower than other mvmt impairment.
● Thoracic outlet syndrome:
○ Diagnosis: Thoracic outlet syndrome (with vascular occlusion and/ or axonal
conduction loss??)
○ Treatment:
■ Medical referral:
● Signs or symptoms of vascular occlusion
■ Conservative management:
● Re- train motor control:
○ Sub- optimal spinal posture:
■ Thoracic kyphosis= scapular anterior tilt
○ Scapula:
■ Facilitate upwards rotation/ posterior tilt
○ Taping as an early strategy= provide postural awareness.
● STT: Hold- relax or massage.
○ Pectoralis minor, scalenes, levator scapulae, rhomboids
● Mobility:
○ Rib 1 and 2: caudo- medial glide to restore posterior
rotation mobility (lost due to scapula elevation).
○ Management:
■ Motor control:
● Thoracic= endurance and then add movements with perturbations
(see lumbar motor and postural control above).
● Scapula= peri musk stuff: wax on wax off against wall with towels,
shoulder elevation with theraband forcing arms into ER:
○ Motor control parameters 3x 5- 20 up to 3 x per day (need
to indicate will see what pt can do bcs form fatigue).
■ STT:
● Provide a stretch for related muscles (60s+ x3, x2; 1-2 minute rest
b/n sets).
■ Address contributing factors:
 ● Work ergonomics/ postures
● Overhead limb use (sport and work)

● Thoracic disc herniation (myelopathy):

○ Red flag = medical referral (if acute and progressive= ER? If prolonged= GP).
■ =/> 3/5 = Babibinki, >45, gait abnormality, hoffmans, inverted supinator
(refer to pg 15 wk 6 notes).
● Ankylosing spondylitis:
○ Treatment / Management:
■ Poor response to physical treatment alone
■ Role:
● Education about Dx, prognosis, other Rx options, how to Mx Flare
ups, online resources, support groups
● Exercises
○ ROM
○ Stretching
○ Postural
○ Aerobic
○ Hydrotherapy
● Pain & fatigue Mx
● Promote & teach self-Mx
● GP referral for medical Mx
○ NSAIDs - first line
● Scheuermann's Disease
○ Treatment:
■ Address related impairments of spinal Fx e.g. mobility:
● Teach AROM exercises to maintain/ regain mobility
● Stretches to maintain muscle length
● Can teach how to foam roll etc.
○ Management:
■ HEP for related AROM exercises taught in clinic
■ Activity modification:
● Only temporary and still keep them as active as possible
● MODIFY/ adapt. DO NOT just tell them to stop! Need to maintain
movement.
○ Maybe limit heavy overhead movement but add in AROM
exercises to maintain this.
○ Cycling, swimming, yoga etc.
■ Prognosis/ reassurance:
 ● Usually self limiting with the pain ceasing once skeletally mature.
■ Referral:
● GP for NSAIDS
● Possibly bracing if kyphosis is more severe and skeletally
immature.

Stretched positions for annoying muscles include this for; massage, HR, home stretch:
● Pectoralis minor:
○ Assessment/ HR: stabilise rib attachment of pec minor (place your hand over the
patients), apply retraction/ posterior tilt to scapula via coracoid/ shoulder.
○ Home stretch: standing in door frame, align shoulder of affected pec minor and
lean into the door pushing your shoulder backwards.
● Quadratus lumborum: Patient seated, arms crossed, feet supported on the floor.
○ Guided to relax into thoraco- lumbar flexion.
○ Fixate iliac crest; patient moves into contra- lateral trunk flexion.
● Piriformis: Hip flexion to 90, full external rotation +/- adduction/ further flexion.
● Erector spinae: Patient seated, arms crossed, feet supported on the floor.
○ Full spinal flexion (slump) without flexing cervical spine.
● Upper trapezius: Fixated shoulder girdle vias acromion. Head/ neck flexion and
contralateral lateral flexion +/- ipsi or contralateral rotation of the head.
● Levator scapulae: Fixated medial angle of scapula. Head/ neck flexion, contralateral
lateral flexion and contralateral rotation.
● Scalenus posterior: Fixated first and second rib (via web of hand stabilising superior
aspect). Full head and neck flexion with contralateral lateral flexion and contralateral
rotation.
● Scalenus anterior and medius: Fixated first and second rib (via web of hand stabilising
superior aspect). Retraction, removal of cervical lordosis, contralateral lateral flexion,
with ipsilateral rotation (rotation biases medius).
● Sub- occipital extensors: Occipital flexion. Support head with both hands + produce
rotation in the sagittal plane with slight retraction of the occiput.