Manual Therapy and Exercise

Course Manual
 3 Discoveries

1. The details: usefulness of biomechanical

expertise
2. The larger picture: dysfunctional movements
are as important as biomechanical changes
3. Patterns of Pain approach
 Our Clients Are Like Laptops?
1. Mobility dysfunction: “hardware issues”
requiring manual therapy
2. Motor control dysfunction: “software issues”
requiring corrective exercise
 Guiding Principles
• Mechanical pain ALWAYS involves motor control
problems and SOMETIMES mobility problems.
• Treatment includes a combination of exercise
(motor control) and manual therapy (mobility).
 Treatment Plans That Engage Patients
Involve:
1. identifying a Pattern of Pain
2. identifying dysfunctions
• motor control

• mobility

3. delivering effective manual therapy

4. prescribing corrective exercises
 Integrate Four Systems
1. CBI Patterns of Pain
2. CBI Stages of Recovery
3. Orthopaedic Division Manual Therapy
4. Functional Movement Systems
Functional Movement Systems
– understand and complete 4 basic tests.

– decide which exercises are required based on motor

control problems or strengths evaluated by these tests.
– progress the challenge based on observed improvement
on test-retest
 Patterns of Pain - Summary

History:
– Site of dominant pain

– Constancy of pain

– Response to flexion movement / position

Physical exam:
– Back dominant, extension response (PEP/PEN)

– Leg dominant, flexion response (FA/FR)

 Back dominant Leg dominant

Constant /Intermittent Intermittent Constant Intermittent

Pattern 1 Pattern 2 Pattern 3 Pattern 4

Pattern 4 Pattern 4
FA FR
Pattern 1 Pattern 1
PEP PEN
 Physical Examination
Manual Therapy

• Designed to verify or refute the history

• History takes precedence over physical
examination
• BUT the physical examination must support
the history
 Six Movements Assessment
1. Walking
2. Crouching
3. Squatting
4. Single leg stance
5. Stride stance extension
6. Dorsiflexion wall test
Purpose of the Six Movement Assessment
• Look for dysfunctional movement, not a
diagnosis.
• Identify dysfunctional movement to be analyzed
with lower quadrant scan.
 Single Leg Stance
If your client can’t “hit the mark”, then why not?
– Poor trunk stability?
– Weak hip abductors?
– Poor lower extremity proprioception?
– Pain with single-leg weight bearing?
 Walking
• Pick up any deviations
• If none, go faster - to maximum speed
– Then on heels and toes
• Note:
– Pain, weakness or stiffness
 Crouching
• Notice any deviations
• Note:
– Pain, weakness or stiffness
 Squatting
• Establish ability to squat to chair level
• Note:
– Pain, weakness or stiffness
 Squatting - the “Hip Hinge”
• Important functional movement:
– By discharge goal is that everyone can squat
• A hip hinge ultimately spares the spine &
loads hips so that hips do most of the dynamic
work.
  
The Squat / Toe-Touch Paradox

Rounding of the spine

• Great during a toe touch
• Disaster during a squat
 Single Leg Stance
• Important functional movement:
– Walking, running, stairs, lifting, pivoting
• Note:
– Pain, weakness or stiffness
 Single Leg Stance
Balance Sequence
• Challenges balance, trunk stability & control
• Establishes step & stride mechanics
• Note:
– Pain, weakness or stiffness
 Single Leg Stance
Balance Sequence
• Start with feet together, hands on hips
• Tandem stance
• Single leg stance with lifted leg at 30 or 90
degrees flexion
• Note:
– quality of position & symmetry
 Stride Stance Extension
Description
• One leg on a stool, other extended back; arms
raised
• Lean back
• Note:
– Pain, weakness or stiffness
 Dorsiflexion Wall Test
Description
– Stand facing wall
– Great toe placed on line 10 cm from wall
– Touch knee towards wall in-line without
lifting heel
 Conclusion Assessment of
Six Movements
Distinguishes the client who has pain but whose
movements are well-preserved
vs.
The client whose pain is altering their
movement or is in pain due to moving poorly
 Lower Quadrant Scan
• Multisegmental movements
• Seated thoracic rotation with dowel
• Thomas test
• Long sitting
• Active SLR
• Hip clearing exam
 Lower Quadrant Scan
• Isometric abdominal testing
• FABERs
• Side lying hip abduction
• Prone hip extension
• Prone extension x 10
• Palpation
 Multisegmental Movements
• Flexion: feet together, knees straight, bend
forward

Functional: able to touch toes, symmetrical

spinal curve, posterior shift of pelvis, no pain
 Multisegmental Movements
• Extension: feet together, knees straight,
bend backward

Functional: scapular spine clears the calves,

ASIS translates forward and clears toes,
symmetrical spinal curve, no pain
 Multisegmental Movements
• Rotation: feet together, knees straight, arms
held at 30 degrees; rotate to left and right

Functional: 100 degrees total, 50 degrees each of

thoracic and lumbopelvic/hip rotation, no pain
 Thomas Test
• Tests the overall mobility of the hip flexor
muscles and the anterior hip capsule

Functional: the non-supported thigh lowers

to horizontal with 90 degrees of knee flexion
and no abduction
Seated Thoracic Rotation with Dowel
• Examines rotational ability through the
thoracic spine
• Perform with feet on the floor and knees
together; dowel behind head
• Should be 50ᵒ each direction
 Active SLR

• Evaluates core control, pelvis position,

maintaining extension with one hip while
flexing the other
• Compare active vs. passive SLR
 Isometric Abdominal Testing
• Evaluates the ability to do an isometric
stabilizing contraction in crook lying
• Progressions: alternate leg lift, alternate leg
lower, double-leg lower
 Hip Rotations and Quadrants
• Determine if hip joints are mobile or stiff
• Clarify if hip movements are/are not
associated with lower back pain
 FABER Test (Hip Flexion, Abduction and
External Rotation
• Tests the effect of hip flexion, abduction and
external rotation overpressure on the hip and
lumbar spine

Functional: knee should be within two of their

fist-widths from the table
 Side Lying Hip Abduction
• Performed with hips and knees extended
• Active, with overpressure following to
determine passive mobility
• manual muscle testing at mid range
 Hip Extension
• active, passive mobility and manual muscle
testing
 Prone Extension x 10
• Establishes PEP or PEN
• Also a more accurate measure of physiological
lumbar range than standing extension
 Palpation
• Central and unilateral PA’s
• Muscle palpation
 Assessment
Once we’re done, what do we know?
1. Pattern of Pain
2. Mobility dysfunction: “hardware issues”
requiring manual therapy
3. Motor control dysfunction: “software issues”
requiring corrective exercise

Treatment intensity will be guided by the stage of

recovery
 Stages of Recovery
• A structured approach to treatment planning
– Stage 1: Pain Control
– Stage 2: Recovery of Movement
– Stage 3: Recovery of Function
• Provides focus to progression
• Don’t be in two stages at once
 Stage 1: Pain Control
• Goal is to abolish or maximally reduce pain.
• Focus of treatment is to manage pain by:
– using specific positioning/movements on a scheduled
basis.
– encouraging reasonable levels of activity.
– Initially avoiding aggravating movements/positions, as
should complete bed rest.
 Stage 1: Pain Control
• Pain control is primarily achieved via self-
treatment strategies.
• If the patient has a directional preference,
manual therapy forces can be applied in the
direction of pain relief
– P1 PEPs usually improve with extension-based manual
therapy
 Stage 2: Recovery of Movement
• Goal is to recover a functional amount of
movement.
• Focus of treatment is to increase movement and
tolerance to activities that previously caused or
aggravated their typical pain.
 Stage 2: Recovery of Movement
• If the patient has a directional preference,
manual therapy forces are applied in the
direction opposite the pain relieving direction.
– P1 PEPs usually improve with flexion-based manual
therapy.
 Stage 3: Recovery of Function
• Goal is to return to all of their normal functional
activities and maintain a durable recovery.
• Focus of treatment is to improve physical
conditioning and ability to perform all activities
– tolerance
– endurance
 Stage 3: Recovery of Function
• Strong role for exercise
– Don’t forget pain control strategies
– Manual therapy (as required)
 Why Do We Do Manual Therapy?
• Manual therapy technique selection is based
on observed movement restriction
• Successful manual therapy technique results
in:
– less pain and stiffness
– improved quality and range of movement
 Other Manual Therapy Effects
• Manual therapy can be used to decrease pain
and improve motor control
• Treat an area away from an acutely painful
region
 Novice vs. Expert
and Manual Techniques
• Novice clinicians have performed as well as
expert clinicians in manual therapy studies.
• You don’t need to be an expert to use these
techniques.
 Setting Expectations

• Therapist and client belief in treatment influences outcome.

• We can shape patient expectations by what and how we talk to
patients.
• Positive framing expectation of outcomes.
 Manual Techniques
• Simplify clinical reasoning
– Move it and move on
– Complex biomechanical/joint specific
models of reasoning are not required
• Use test-retest during the treatment session to
determine effectiveness.
 Flexion Techniques
Stage 2, Pattern 1 PEP
• Initial emphasis on movement into extension
• Manual therapy assists with regaining flexion
 Manual Therapy Treatment
• Do both myofascial and articular techniques
within a treatment session
• Address, with manual therapy or exercise,
joints above and below the problem
 Soft Tissue Mobilizations
Erector Spinae
Quadratus Lumborum
Multifidus
 Flexion Techniques
Unilateral flexion mobilization
Triplanar “top side” flexion
Innominate posterior rotation
Hip flexion mobilizations with belt
Old Chicago technique – general manipulation
 Stage 2 Mobility Sequence
• A mobility sequence of exercises is designed to
restore movement.
• Use
– post-manual therapy
– as dynamic warm up
• Adherence to exercise is improved when
reinforced after manual techniques
 Corrective Exercise Pathway
1. Mobility before stability
2. Stability before movement
3. Movement before strength
 HOT - Exercise Essentials

Hands-on cue Push to check stability

Own the position Grip, tear, turn, tighten
Teach the focus Core, proper position
 The Perfect 20 Minutes

• Client comes 15 minutes early

• Aerobic and dynamic warm-up
• Ready in the gym at scheduled appointment
time
 The Perfect 20 Minutes

• Technique check & proceed to new exercise

• Education & manual therapy
• Finish with exercise
 Stage 1
• Movement screen
• Lower quadrant examination
• Begin pain control
management
Stage 2

• Warm up with aerobic exercise

• Manual therapy
• Mobility and basic exercise sequence
Stage 3

• Dynamic warm up: aerobic

exercise and mobility sequence
• Manual therapy as required
• Four basic movement tests
• Establish corrective exercise
program
 Stage 2

 Warm up with aerobic exercise

 Manual therapy
 Mobility and basic exercise sequence
(taught over 2-3 sessions)
 Stage 3

 Dynamic warm-up; aerobic exercise and

mobility sequence
 Manual therapy (as required)
 4 basic tests (movement – based)
 Identify relevant corrective exercises
 Extension Techniques
Stage 2, Pattern 2
• Initial emphasis on movement into flexion
• Manual therapy assists with regaining
extension
 Extension Techniques
Psoas release
Unilateral extension mobilization
Triplanar “top side” extension
Innominate anterior rotation
Hip extension mobilization
 Pattern 4 - Flexion Relieved
Frequently termed
“Symptomatic Spinal Stenosis”

Accurately termed
“Neurogenic Claudication”
 Pattern 4 FR
• Leg dominant pain
• Intermittent pain
• Leg pain relieved with flexion
• Worse with movement and/or position in extension
(e.g. walking, sustained overhead work).
• +/- conductive loss
 P4 FR Common Impairments
• Reduced hip mobility: extension, internal
rotation ROM.
• Reduced ROM thoracic spine, lumbar spine
and knee extension.
• Reduced ROM ankle dorsiflexion.
• Decreased balance resulting from reduced
lower extremity strength.
 Stages of Recovery – Pattern 4 FR
• Stage 1 – Pain Control
Flexion exercises, pacing, positioning
• Stage 2 – Recovery of Movement
– Manual therapy, stretching

• Stage 3 – Recovery Function

– Stabilization, strengthen, cardiovascular
– Most time is spent in Stage 3
 Thoracic, Sacroiliac and Hip Techniques

• Hip posterior glide/Sacroiliac gap

• Direct SI gap
• Manual iliopsoas and rectus femoris stretches
• Rollover Thoracic Gap/Flexion
 Squat Assessment and Exercise
 Great squat!
 Proceed to load (lifting boxes, barbells,
dumb-bells, kettlebells)
 So-so squat!
 Correct by teaching and cueing proper squat
technique
 Awful squat!
 Begin training in supine and 4-point
 Stage 3
Individualizing An Exercise Program
• Client is moving better and without much pain
• Exercise programs are tied to assessment of
movement and activity goals
 Stage 3
Individualizing an Exercise Program
• Exercises grouped into progressions based on
evaluation of four basic tests
 The Four Basic Tests in Stage 3

• Active Straight Leg Raise Mobility

• Thoracic Mobility

• Rotary Stability
• Trunk Stability
 The Four Basic Tests
• Perform these tests, identify which are dysfunctional
• Correct dysfunction in order
– Establish mobility competency

– Static motor control competency

– Dynamic motor control competency

– Performance and strength/power exercises

 Example
Limitation of Active Straight Leg Raise:
– Leg lift in doorway
– Leg-lock bridge
– Half-kneeling chop
– Diagonals
– Single leg deadlift patterning
– Suitcase deadlift
– Single leg double arm with dumbbell
 Positional Progressions
Positioning exercises: Standing progression:
– Supine/prone  symmetrical stance
– 4-point  single-leg
– ½ kneel  split-stance
– Standing
 Active Straight Leg Raise
Test Description
1. Equipment needed: 2 x 6” board, dowel, ruler
2. Client in supine, arms at 45 degrees, board placed
under knees
3. Measure mid-point between ASIS and knee joint line;
place ruler there
4. Non-moving limb remains on board
5. Ask client to lift the other leg and hold
6. Align dowel from ankle to floor
 Active Straight Leg Raise
Evaluation
Functional
Dowel positioned between ASIS and board
Dysfunctional
Dowel on board or below
Note
Asymmetry and test active vs. passive
 Thoracic Mobility
Test Description
1. Standing feet together arms at 30 degrees
abduction
2. Turn torso to left and to right
 Thoracic Mobility
Evaluation
Functional
Standing > 100°
Sitting > 60°
4-point > 50°

Dysfunctional
ROM less than these values
Note
Asymmetry
 Rotary Stability
Test Description
1. Quadruped position, 2 x 6” board between hands
and knees.
2. Client flexes the shoulder and extends the
opposite hip and knee.
3. The client brings elbow to knee while remaining in
line over the board.
4. Client finishes by flexing the shoulder and
extending the leg again.
 Rotary Stability
Evaluation
Functional
Able to perform the movement
Dysfunctional
Not able to perform the movement (loses balance,
can’t touch knee to elbow, touches out of line with
board)
Note
Asymmetry
 Trunk Stability
Test Description
1. Goal is to initiate movement with the upper
extremities in a pushup pattern without
allowing movement in the spine or hips
2. Males: perform a repetition with thumbs
aligned with the chin
3. Females: with thumbs aligned with the clavicle
 Trunk Stability
Evaluation
Functional
Able to lift the body as a unit; chest and stomach come
off the floor simultaneously

Dysfunctional
Unable to move as a unit; trunk collapses into extension
or rotation

Note
Asymmetry
 Wrapping Up

• Link treatment to the patients functional goals—

let’s be able to explain why we’re working on what
we’re working on
• Integrate
• Patterns of Pain
• Manual therapy
• Corrective exercises
• Stages of Recovery
 Wrapping Up

• Add exercises based on movement test results

• Progressions: Mobility
Stability
Motor Control
Strength/Power