Post 76 Vestibular dysfunctions

1. “The vestibular system is responsible for sensing motion of the head and maintains stability of images on the fovea of the retina and postural control during that motion” 

I am going on a limb here. Vestibular dysfunctions are not my specialty. I will be learning along with you here. If there are folks out there that understand this better than I do, please comment on this article where I am out of place or my thinking is not correct. 


In school, we learned about the vestibular system over the course of 2 days. It sounds like a lot of learning, but put it into perspective. This equates to about 4 hours of learning in comparison to about 2,000 hours of overall course work. 


The vestibular system detects motion of the head. The apparatus is located behind the eye and is very small. It communicates with the brain in order to indicate where the body is at in space. 


2. “The vestibular receptors in the inner ear provide an exquisitely accurate representation of the motion of the head in 3 dimensions”


The system is able to determine tilts of the head in each direction and acceleration of the body. 


3. “Disorders of the vestibular function result in abnormalities in these reflexes and lead to sensations that reflect abnormal information about motion from the vestibular receptors”


Remember, this system communicates with the brain regarding tilting forward, backwards, rotating left and right, and acceleration. When this system is not working smoothly, you may be still, but the brain may get a message that you are actually moving. You may be straight, but the brain sees that you are tilting. I can remember going to the fun house at Navy Pier. There is a bridge that is no more than 2 inches off of the ground, but visually, it seems like the bridge is moving. Watching people attempt to cross the bridge is amusing. Unfortunately, this is how people with vestibular dysfunctions perceive daily life. Not so amusing. 


4. “Best visual acuity is obtained when images are projected on the fovea of the retina…occupies a small area of the visual field, but movements of an image off the fovea by as little as 1 degree can cause substantial decreases in visual acuity”


The fovea is like a hole that the image from the eye has to fall into in order for the image to be perceived clearly. If the eye doesn’t follow the image perfectly, the image will then become blurry. 


5. “Normal activities of daily life (such as running) can have head velocitieis of up to 550 degrees/second, head accelerations of up to 6,000 degrees per second squared, and frequency content of head motion from 0 to 20 Hz. Only the vestibular system can detect head motion over this range of velocity, acceleration and frequency”

The vestibular apparatus is very sensitive to movement. It can react quickly to head motion and if there is a deficit in this system, all of the above descriptions will be limited. 


6. “The incidence of dizziness in the United States is approximately 5.5%, which means that more than 15 million people develop the symptom each year”


This is one of the chief reasons for ED visits. As a PT student, one should follow his/her passion. With the pleasantries out of the way, the PT student should become great at treating diseases that are going to keep that PT in business. For instance, if you are in a small town of 10,000, then you will end up seeing about 500 cases of balance issues in the year. Back pain will give you about 2,500 cases per year. If you get really good at treating these two incidences, you will have business for life, assuming that you can get the public to become aware of your services. 


7. “For patients over 75 years of age, dizziness is the most common reason they see a physician…it has been reported that more than 70% of patients with initial reports of dizziness will not have a resolution of symptoms at a 2-week follow-up”


Older patients will have more occurrences of dizziness than younger patients. Dizziness is not going to be cleared up rapidly in most patients, but some cases of dizziness can improve within 1-3 visits. It is important that the therapist is trained in treating different types of dizziness. 


8. “Many patients and clinicians use the imprecise term “dizziness” to describe a vague sensation of light-headedness or a feeling that they have a tendency to fall…Generally, most complaints of being “dizzy” can be categorized as light-headedness, disequilibrium, vertigo, or oscillopsia”


Not all “dizzinesses” are the same and because of this, they aren’t all treated the same. You will see in the next points.


9. “Light-headedness is often defined as a feeling that fainting is about to occur and can be caused by nonvestibular-factors such as hypotension, hypoglycemia, or anxiety”


Someone fainting does not need balance exercises. They require medical attention. The physician needs to be made aware, as this could be a sign that the cardiovascular system is not working correctly. Sometimes it can be as simple as giving advice to sit for a minute before standing and stand for a minute before walking. The physician needs to be aware of this symptom in order to determine which advice is needed prior to treatment. 


10. “Disequilibrium is defined as the sensation of being off balance…associated with nonvestibular problems such as decreased somatosensation or weakness in the lower extremities”


The somatosensory system is the body’s communication system between where the joints and limbs are in space with the brain. For instance, I can touch my nose or feed myself without seeing either my hand or my mouth. If the somatosensory system is not intact, I would have trouble feeling the ground with my feet and telling whether my weight was on my heels or on my toes. This is a big problem that could lead to falls. 


11. “Vertigo is defined as an illusion of movement…tends to be episodic and tends to indicate pathology at one or more places along the vestibular pathways”


This means that you feel that you are moving, even though you are not. Think of being on a boat and how that feels. When you feel like this on land, something is not working correctly. This sensation could be due to BPPV, “ear rocks” that get out of place, or a lesion in the vestibular apparatus. 


12. “Oscillopsia is the experience that objects in the visual surround that are known to be stationary are in motion…can occur in association with head movements in patients with vestibular hypofunction because the vestibular system is not generating an adequate compensatory eye velocity during a head rotation”

This isn’t the first time that I heard this term, but I am also not very familiar with this phenomenon either. I am just learning this entire topic of vestibular rehab, but I realize that when you are standing still and you see things moving…something ain’t right!
I have personally never seen this symptom in the clinic, but I am excited to see a patient with this complaint because after taking a course with Evidence CEU, I feel more confident in treating these types of patients.
“…the bedside examination of eye movements can be of primary importance in defining and localizing vestibular pathology”

I have to speak with regards to orthopedics for a second, but there is a slow wave of support coming forth that is negating the need for expensive tests prior to an actual assessment of the patient. This also seems to hold true for vestibular dysfunctions. Much can be learned by listening to the patient’s history and doing examinations while watching the patient’s eyes during different movements. Prior to taking the course with Mickey Shah, PT, DSc, cert. MDT, FAAOMPT, vestibular certified (Emory), I had little understanding of the vestibular system and its effect on function. I have more confidence now in performing a bedside examination, which can give great insight into the patient’s vestibular system.
The next couple of pages go into depth on the special testing that is used to detect vestibular pathology. I won’t go into depth, but when going to see a vestibular therapist, the following tests should be done (assuming there are no contraindications to performing the tests such as cervical instability)
            Head thrust test
            Positional testing (such as Dix-Halpike and roll testing)
            Dynamic visual acuity
“The most frequent cause of UVH (unilateral vestibular hypofunction) is vestibular neuronitis, which is commonly caused by the herpes simplex virus…may experience vertigo, spontaneous nystagmus, oscillopsia, postural instability and disequilibrium”

Essentially, this means that there is an issue with the vestibular system sending afferent signals to the brain. In short, the balance system in the ear is malfunctioning, but only on one side. This has the potential to cause a patient to feel “off balance”, possibly have blurred vision, and maybe lean to one side.
“The most common cause of vestibular hypofunction on both sides (BVH) is ototoxicity…experience gait ataxia, postural instability and oscillopsia”

This is a patient that I have seen a few times. When you see it, you don’t forget it. These patients look like they have a stroke in the cerebellum. They have trouble walking and initiating gait. They look like they are going to fall (and they typically do without a walker). It’s interesting in that if they are allowed to touch something stable with fingertips, they look absolutely normal. The body’s somatosensory system would then take up the slack for the dysfunctional bilateral vestibular system.
In the end, vestibular rehab can be very beneficial to help patients that have these dysfunctions. If you have any of the above symptoms, do not be satisfied with the statement “you have a weak core”. If you are losing your balance, special testing should be done in order to determine the cause of your balance limitations. If you feel sensations of movement when you are still, or you see things moving, that you know should be still, go see a therapist trained in the methods discussed above. Never be too shy to ask your therapist their qualifications to treat these disorders. I am proud of what I know regarding orthopedics, but also take ownership over the fact that I have much to learn in all of the other aspects that I allowed to play second fiddle while I was studying about spinal conditions and other orthopedic topics.
Schubert MD, Minor LB. Vestbulo-ocular Physiology Underlying Vestibular Hypofunction. Phys Ther. 2004;84:373-385.

Post 75. PT in the ED

“Between 2000 and 2011, the number of ED visits in the United States rose by 26%, and this trend is expected to continue with implementation of the affordable care act.… Nearly 30% of hospital-based EDs have closed since 1990”
Essentially, this means that more and more people are using the emergency department, but staff sizes aren’t increasing as much as they should be according to the increase in usage. With the addition of the affordable care act, more people are insured. Although this sounds good, the reimbursement rate for providing the same service from last year has gone down this year.
Rant: this just chaps my ass. How many different businesses will allow the customer to pay less next year than they did this year? I would love it if the price of milk kept dropping year-over-year unfortunately for healthcare providers the value of saving lives has gone down year to year.

“…nearly half of all ED visits can be classified as semiurgent (35%) or nonurgent (8%).”

This means that the “emergency department” is no longer used for emergencies. This takes resources away from those that are urgent in order to treat those that are not as urgent. The article speaks of using ED physicians to treat sprains and strains, which could be treated by a primary care physician’s office.


“With increasing numbers of patients seeking care in EDs for nonurgent musculoskeletal conditions, physical therapists have the knowledge and skills required to play an increased role in the primary care of patients and to help mitigate overcrowding and improve time efficiency in the current ED environment”

This was a mouthful. The authors are making the assumption that the types of patients presenting to the emergency department will not change. This means that almost half of the patients coming into the ED do not actually need “emergency” services. Because of this, PT’s can play a major role in assessing and treating musculoskeletal conditions. Doing so would take the resources (emergency physicians) and allow these services to be directed towards the patients that need this service specifically. This would reduce wait times in the ED. Having been to the ED at times with my daughter (one of the prices of being a new parent), I totally agree that wait times can be a deterrent to going to the ED. For some problems though, we can’t wait.  

“This practice (physical therapists in the ED) was first described in the United States in 2000 and was identified as an ‘emerging practice’ by the American Physical Therapy Association.”

My specific hospital started using PT’s in the ED and I am proud to say that I was part of the catalyst for starting this program. We go up to the ED in order to assess spinal pain and balance/vestibular conditions. I find that our opinion is valued as a consultation by the ED physicians, but I have no objective data to back up that belief.

“Physical therapists function as secondary practitioners and require referrals from medical doctors to examine and treat patients”

This is true to an extent. PT’s in this state I practice require a referral in order to treat a patient, but not to evaluate a patient. This is not true for every state, as each state has its own practice act.  

“Physical therapist practice in the IUMH (Indiana University Methodist Hospital) ED began in 2002 with one full-time physical therapist…evaluate more than 2,000 patients annually”

In the hospital from the study, the article notes that the total number of hours of PT’s working in the ED has increased over time. This is not the case yet in our hospital, as the therapists are essentially “on-call” in the ED from their respective locations in the hospital. For instance, I work in the outpatient setting, but when there is need for a spine evaluation, I get called to go upstairs when needed/able.

“The reason for dissatisfaction reported in both cases (both from staff physicians) was that the ED physical therapist was not available at the time the physician sought to refer a patient”

This is the only reason for being dissatisfied?! This is a great sign for the future of PT’s in the ED.

“…the following 3 items were rated as most valuable in both 2004 and 2011: (1) provide specific instructions regarding the proper and safe use of assistive devices; (2) provide interventions that are an alternative to pain medication; (3) educate patients regarding injury prevention, safety, and body mechanics with daily activities.”

We look at gait training and think that it is easy. We are trained very well to do this and should take ownership over performing gait training and gait analysis. As PT’s, especially outpatient PT’s, gait training with an AD is something that should be done before a patient gets to outpatient, but this is a part of our profession. We should not allow other professions to own this. In taking ownership, this needs to be done for all patients that need the assistive device, regardless of setting.

Pain management seems to be pushed hard in the media now, as there is an opioid epidemic. As therapists, we can educate on the hurt vs harm mentality. Patients need to understand the difference. Unfortunately, pain can cause patients to become fearful. This places the patient into a cycle in which any activity that causes pain should be avoided. This will only prolong the cycle of pain.  

I don’t believe that there is any other profession that can assess body mechanics with as much depth as PT. 
The end result of the article is that physicians are pleased with PTs in the ED and note that PTs are the most qualified to assess body mechanics, gait training, and return to work. The chief gripe was lack of availability of PTs when requested. This is another avenue for hospitals to increase revenue, as this is considered an outpatient visit. 
Fruth SJ, Wiley S. Physician Impressions of Physical Therapist Practice in the Emergency Department: Descriptive Comparative Analysis Over Time. Phys Ther. 2016;96:1333-13341

Post 74

I’ll readily admit that I didn’t have time to write this week. It’s been a hard month for me, avoiding death twice. Therefore, I borrowed from some of my previous research writings from the ladt year. Enjoy. 

Cleland JA, Childs JD, Fritz JM, et al. Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Phys Ther. 2007;87(1):9-23.
Inherently lower risk of serious complications, thoracic spine thrust manipulation might be a suitable alternative, or supplement, to cervical spine thrust manipulation.

To develop a CPR to identify patients with neck pain who are likely to benefit from

thoracic spine thrust manipulation based on a reference standard of patient-reported improvement
prospective cohort study of consecutive patients with mechanical neck pain

Inclusion criteria

b/t 18 and 60

primary complaint of neck pain

with or without unilateral upper-extremity symptoms

baseline NDI of at least 10%

Exclusion criteria

identification of red flags

h/o whiplash within 6 weeks of the examination

diagnosis of cervical spinal stenosis,

evidence of any central nervous system involvement

s/s of nerve root compression (at least 2 of the following)




4 PT’s underwent standardized training regimen with a mean of 12.3 y/o experience

Self-report measures

body diagram





mode of onset, nature and location of symptoms, aggravating and relieving

factors, prior history of neck pain
Neuro screen

Postural assessment

Cervical ROM

symptom response

length and strength of muscles of the upper quarter and endurance of the

deep neck flexors
Special tests





all treatment standardized

Each subject received 3 different thrust techniques to the T/S twice per session

seated distraction

supine upper thoracic spine manipulation

Middle thoracic spine manipulation

Cervical ROM exercise

10 reps 3-4x/day

fingers on chest and chin on fingers (rotation bilaterally)

GROC with a score of +5 categorized as a successful outcome

high threshold was authors’ way of attempting to isolate the treatment for

improvement (VG: there still may be rapid responders without treatment
or with a separate treatment)
Those without a +5 GROC score were treated for a second session with thrust

manipulations as in the first treatment, with a f/u in 2-4 days.
Those that didn’t reach +5 were then seen as unsuccessful. At this point, the

study was complete and treatment was administered as per their PT.
Sensitivity, Specificity, and positive likelihood ratios (LR’s) were calculated for

those variables that reached significance at a P<.10.
80 subjects recruited and 2 subjects dropped out of the study

23 subjects reported “successful” outcome based on GROC after the first session.

19 after session 2 (42/78)

“successful” outcome group was significantly better with both pain and

disability than the “unsuccessful” group.
6 potential variables based on data analysis are as follows:

No symptoms distal to the shoulder

looking up does not aggravate symptoms

<30 days since onset of injury

<30 degrees of cervical extension


diminished upper thoracic spine kyphosis

14/15 subjects + on 4/6 criteria and 32/37 subjects + on 3/6

all had successful outcomes

+LR for 4/6 + variables is 12.0 and post-test probability of success is 93%

+ LR for 3/6 + variables is 5.5 with post-test probability of success at 86%

Clinicians should look for at least 3/6 variables in order to guide the utilization of

the CPR.
CPR is able to a priori determine who may benefit most from T/S thrust

fulfilled the purpose of creating a CPR and the authors note that additional studies

should be performed to validate the study with a long-term analysis and utilizing an RCT comparison group.
Clinician perspective: This was a well-run initial study. Without validation, I would utilize the CPR should the patient not respond to an assessment/treatment approach that was not demonstrating improvement. In hindsight, this CPR was not validated. Many patients rapidly responded to the manipulation. As a clinician, I would still keep this in mind when treating patients that were not responding to a preset treatment paradigm. There are some questionable actions in this study, for instance, I can’t remember ever using a Roo’s test for someone with cervical complaints, as this is a test for TOS.

Movementthinker post 73


Today’s lesson is about feet. That’s right…feet. Not that I have a fetish or anything, but I was intimidated by feet after meeting the oh great guru of feet (that’s right…there is a feet guru) Dr. Tom McPoil. I didn’t have much of an interest in feet to begin with, but after meeting this guy, I had even less interest (not that he was boring, but I didn’t share his passion for feet). Not that feet aren’t interesting, but seriously…they’re feet. Making a career on feet wasn’t my cup of tea. I chose spines…or more romantically…spines chose me. Dr. McPoil was intimidating. He one of the best PTs in terms of the biomechanics of feet and foot pain. I demand a lot of my students and he was demanding of us. I took some of the information that he gave us and applied it to my career, but it had nothing to do with feet. He spoke of how to achieve excellence. Do what the others aren’t willing or able to do.

Fast forward about 10 years (I now have some greys) and I am a little more interested in feet. Not that I want to treat them all day mind you, but a little more interest than none. I mean when the foot hits the ground is when the machine can start to move. I might as well get a little better understanding of the mechanics of the foot.


This weeks article will again be a learning lesson for both you and me. I knew little about the feet (compared to my knowledge of the systems above the feet), but now I know just a little bit more than nothing.

“Hallux Valgus is a common foot deformity, presenting in 35% of women over 65 years of age…hallux shifts laterally and the first metatarsal medially. Other alterations may include collapse of the arch and rolling of the hindfoot”

Do you know what this means yet? When I hear collapse of the arch, I think of the Greek dynasty and the collapse of the building. It sounds dramatic, but when the arch of the foot collapses (that is what the author is talking about, but a Greek…or maybe Italian arch…sounds more dramatic) the machine starts to break down. 

When the toe shifts laterally and the long bone of the foot medially, this is commonly known as a bunion (DUM DUM DUM!) These are no good! 
“Hallux deformity is typically accompanied by an overgrowth of bone (exostosis) and tissue that develop on the dorsomedial eminence of the first metatrsal head…called bunion…painful”

I already like this author. First they talk about collapsing of the arches…so dramatic and now they talk of overgrowth of bone. This is usually not good either. I picture something out of a horror film with the overgrowing of bone.

Stated simply, when a tissue is stressed the tissue grows. We typically apply this principle to muscles, but when applied to bone, it is called Wolf’s law. Bone gets stronger (grows) when it is stressed. Sometimes good in the case of osteoprorosis, but sometimes bad in the case of BUNIONS!.

“…its prevalence is highest in females with symptoms of deformity exacerbated by fashion shoe wear”

Story time: I am open and honest with my patients. I tell them that “anything that you do I have either done or am willing to try.” I had a patient that wanted to wear high-heeled shoes to church. She was very stylish and who am I to tell a person that they are stuck wearing flats for the rest of his/her life. She turned my saying around and needless to say, I wore high heels for the first time in my life (at least that I will admit to).

Why do this to yourself? Cramming 10 pounds of sh..potatoes…into a 5 pound bag doesn’t usually go well. Why cram a foot that naturally spreads out during the gait cycle into a shoe that doesn’t allow spreading? Especially those pointy shoes? What gives?

I don’t get it. You keep wearing those shoes and I will keep going CHA CHING$$$! Because at some point, you will end up in the clinic…unless you learn better from reading this.

“The foot may be divided into local regions called the hindfoot, midfoot, and forefoot”

Simply stated, the foot is divided into the back foot, the front foot and the middle foot. I had to go through 7 years of college to understand the above sentence. Not only that, but I had to pay about $70G to understand the same sentence. I gave it to you for free. 

“The hindfoot comprises the calcaneus and talus. The midfoot contains the navicular, cuboid, and 3 cuneiforms. The forefoot has 5 metatarsals and the attached phalanges.”

 The back foot has the heel and part of the ankle joint. The middle foot has the arch bones and the front foot has the toe bones. I love how things can sound so complicated, but be so simple at times!
 Are you a professional? Do you have your own language? We were once told in school that the reason why everything sounds so complicated is so that others don’t try to break into our profession without going through the actual schooling to learn the language. Other professions do this also. Ever try reading all of the screens that I blindly click “accept” to during updates? Legalese. They have their own language.
 “The extrinsics power gait accelerations, while the intrinsics, having both attachments within the foot, act to stiffen the arch and assist in holding the toes on the ground”

 Again, I am not a foot guy, but this makes it easier for me to understand. Foot muscles control the arch and toes and shin muscles control movement of the body. It’s simple, but sometimes simple is best in order to get a base to learn from.
 “Pronation, in the context of poture, indicates a flat or planus foot, and supination indicates a high or cavus foot. Because overpronation accelerates the hallux valgus process, treatment generally bolsters the hindfoot and arch to limit pronation”

 This is a long winded way of saying that treatment for bunions typically emphasizes preventing a flat foot. Now go back and read #6 and you will have the basics of the exercises that will be proposed for treatment of bunions.
I want to touch on this for a second. There is also research, I believe out of Harvard…for some reason I remember the name Lieberman…that indicates that barefoot running could work to hypertrophy the intrinsics of the foot also. I am curious if one takes the exercises proposed in this article in combination with a barefoot walking/running protocol if there will be a change in not only hypertrophy, but also arch height and injury rate of runners. Just a thought.
“Approximately 50 (degrees) of first MTP joint motion is required for walking, whereby the hallux serves as the fulcrum of forward propulsion”

For those that don’t understand this, this means that your big toe must bend backwards about 50 degrees (halfway to completely upright) in order to walk. For those with bunions, or have had bunion surgery recently, this number is a dream. This means that another joint(s) will have to make up for that loss.

“As deformity progresses, overpronation culminates in rolling the first metatarsal off the sesamoids. The hallux follows, turning onto its side…Weight now borne on the medial aspect of the hallux contributes to a lateral push…the hallux and sesamoids may sublux or even dislocate. This releases tension from the plantar fascia”

In short order, if the above happens…you’re up the creek without a paddle. This means that your arch has collapsed. When your arch collapses, you are putting weight more on the inside of the foot. When this happens, you are shoving the big toe towards the pinky toe. If this happens to an extreme, you will dislocate the big toe and it’s all downhill from there. There are some major attachments at the base of the big toe, which support the bottom of the foot. If this gets disturbed…you will have to see a surgeon.
There is a large chunk of the article that goes into origins and insertions of muscles. This is important for your PT to understand, but it is boring, wrote memorization and the layperson doesn’t need to know all of the details (in other words, I don’t feel like typing all of the names of the muscles of the foot. Just know that I read it and if need be, I could restate it.)

 The exercises can be found at

 I have already used these exercises with some patients with awesome results. The patients, both high and low level note cramping of the muscles of the foot and a better awareness of arch height and great toe extension requirements for walking and running. The foot is not my forte, but at least I now can say that I learned (I don’t really remember learning this in PT school) the biomechanics of the foot and feel more comfortable treating and educating if/when I see this in the clinic.
Excerpts taken from:
Glasoe WM. Treatment of Progressive First Metatarsophalangeal Hallux Valgus Deformity: A Biomechanically Based Muscle-Strengthening Approach. JOSPT. 2016;46(7):596-605.

Post 72

Not all press-ups are created equal
“Low back pain (LBP) is a common medical condition that affects p to 80% of the population and can have a profound impact on a person’s everyday life”

This statistic gets used so often that it should be common knowledge at this point that 8 out of 10 people will experience back pain at some point in his/her life. It is almost as common as the cold and it has overtaken respiratory issues for reasons to seek health care.
“LBP was ranked the greatest contributor to global disability and sixth for overall daily burden…in 57% to 89% of people with LBP, no specific etiology can be identified”.

This is huge! Think about this way, LBP is the biggest reason for people to become disabled, but only in about 10% of the cases, can a medical professional tell you the cause of your problem. Might as well play spin the bottle with ten different options. The likelihood of your doctor coming up with the cause of your back pain is as likely as the bottle landing on the cause of your back pain. This is not the doctor’s fault though because not all back pain is the same. If it is not all the same, then it should not all be treated the same. It should be classified, either in a sophisticated manner such as with Mechanical Diagnosis and Therapy or in an unsophisticated manner such as your “core is weak”.
“…subjects with LBP moved more in the lumbar spine during the early phases of forward bending, and that the lumbar spine and hips contributed equally during midranges, similar to controls…when rising from a forward bend, subjects with LBP moved more in the lumbar spine during the first 25% of the movement”

This is getting nit-picky. The easy way to say this is that people with back pain move from the spine in a different way than those without back pain. Depending on which school of thought you listen to, the lumbar spine should remain stable and all of the movement should happen at the hips. If this is the case, then any movement at the lumbar spine would be unacceptable. I don’t fall into this school of thought…but sometimes they are right, especially under load such as a 500# bar or a bag of dog food. Whatever best resembles your lifestyle.
“Three of the more common approaches include the Movement System Impairment (MSI) classification system, the McKenzie approach, and the treatment-based classification system (TBC), with associated clinical prediction rules (CPRs)”

I have a problem with this right off the bat. The Mckenzie approach is formally described as Mechanical Diagnosis and Therapy (MDT). There has been stigma against this approach due to the man that started the approach by “accident” and through careful observation and experimentation the approach has been validated time and again in the hands of those that are qualified. The fact that the authors call it the lay term “McKenzie Method” instead of the official MDT makes it hard for me to not comment.
The TBC is based on clinical prediction rules that have yet to be validated, this is of course aside from the manipulation category. We all know, by now, that manipulations are a powerful tool for all PT’s and Chiro’s to use with patients.
“…the LBP group displayed significantly less lower lumbar extension than did the control group”

If your PT notices this…kudos. What I tend to see is that the upper lumbar spine will extend and then the patient’s pelvis will come off of the table. This has been called “end-range” in some circles, as the lumbar spine has no room left to move and therefore the additional movement happens at the hip. What’s interesting is that I have seen this improve within a session, so the concept of reaching end-range because the pelvis has left the table doesn’t sit well with me. This could be the result of nuclear migration within the annulus, soft tissue accommodation based on the principle of creep or motor learning. I’m sure that there are other possibilities; I just don’t have them at the tip of my tongue (or fingers). Be that as it may, the extension mobility can clear up relatively quickly.
The take home message is that those with back pain don’t move the same way as those without back pain. It sounds like common sense, but it is only common sense when it is proven by people that get paid to tell us…DUH!
Excepts taken from:
Mazzone B, Wood R, Gombatto S. Spine Kinematics During Prone Extension in People With and Among Classification-Specific Low Back Pain Subgroups. JOSPT 2016;46(7):571-579.

Manipulation of the ankle joint

Manipulation of the Ankle Joint.
Now this will be a learning experience for all of us, except for maybe some chiros that follow the research or some professors that teach manipulation. For those of us that aren’t doing manipulations (or grade V mobilizations depending on the state that you live in) on a daily basis, this information is interesting. It will be a learning experience for me to type about it and I may not be able to give a strong background on the information, as I continue to learn about this type of information over time.
“Joint mobilization is delivered as a low-velocity sustained or oscillatory force, while joint manipulation is often defined as a hight-velocity thrust.”

For the most part this is true. Joint mobilizations are graded from I-V (Roman numerals like in Star Wars seems to provide more credibility than simply writing 1-5). Grade five is defined as the rapid thrust that is described in the manipulation aspect.
RANT: The APTA, in its white paper on mobilizations and manipulations, prefers that only PT’s perform these movements because students will become proficient in these movements through schooling. I call BS! I have only met one student in 8 years as a clinical instructor that could walk into the clinic and perform all of the manipulations without error. Most students have difficulty performing basic mobilizations. That’s okay, I am not judging the students (well really I am, as the CI, but I won’t knock the grade because they can’t perform the manipulations). The point is…most PT’s become proficient at the manual aspect of the profession outside of schooling. With all of that said, I don’t agree that PTA’s can’t perform mobilizations as a treatment, assuming the PT is there to assess prior and post manipulation. It is really arguing semantics, as it is not applicable in most situations.
“A number of researchers have demonstrated changes in the excitability of motor pathways following manipulation of the spine”.

When the article speaks of manipulations, the authors are describing the high velocity thrust technique. Performing these techniques causes changes in pain pressure threshold in some patients (think that you could tolerate more pain following the manipulation). In real world sense, it would theoretically require a greater stimulus to create the same pain that you felt prior to the manipulation. There is good work by Stephen (sp) George out of Florida regarding this concept.
“Existing research utilizing transcranial magnetic stimulation (TMS) has also indicated an increase in corticospinal motor excitability following manipulation to spinal joints, but not following low-velocity end-range positioning.”

I’ll be honest, I had to go look this one up. Neuro is not my strong point. I know that we have a brain…the end. Okay…I know a little bit more than that, but not much. I tended to fall asleep during the neuro portion of PT school and would dream about orthopedics. Oh well. Live and learn, it’s actually important.
The basic of the article is that the brain dictates the muscle action. There’s that old saying that “if you see it, then you can be it”. It’s something like that. The brain can increase electrical input to a separate muscle group and the brain can shut down the impulse to muscle groups through imagery, but it can also happen through manipulations, as seen in the article that I am quoting.
“Measuring modulation of corticospinal excitability with active contraction is important, because such changes would suggest an alteration in voluntary recruitment”

This is big for me, as a meathead, because if I can get my brain to send out more electrical impulses, then I, as a meathead can theoretically lift more weight. That’s all that really matters. Unfortunately, there is not a lot of research on this in the PT world, so more to come later when our profession starts to look into athletic performance.
“Individuals in the control group received the hand placement used for a caudal talocrural thrust manipulation only…Individuals in the intervention groups received a caudal talocrural mobilization or thrust manipulation.”

I won’t describe the technique because… “Kids, don’t try this at home”. Just know that it is fairly easy to perform for someone with experience performing manipulations. The manipulation is performed at the foot/ankle complex.
“Our findings indicate that thrust manipulation increased corticospinal motor excitability of the tibialis anterior approximately 30 minutes following thrust manipulation directed at the talocrural joints…there was no significant change in ankle dorsiflexion or dynamic balance following either of the interventions”

Big picture…a manipulation may make you stronger at contracting a muscle, but there doesn’t appear to be functional carryover in this report. It is still big news because there may be other manipulations that not only make your stronger, but also has functional carryover. This will be the fountain of youth once found. A stronger person is a more functional person, assuming that the person has adequate ability to move.
Quotes from:
Fisher BE, Piraino A, Lee Y, et al. The Effect of Velocity of Joint Mobilization on Corticospinal Excitability in Individuals with a History of Ankle Sprain. JOSPT 2016;46(7):562-570.

Lateral shift deformity

Crooked patients 

1. “A lumbar lateral shift (LLS) is defines as a lateral displacement of the trunk in relation to the pelvis…repeatedly associated with discogenic pathology…McKenzie reported that 90% respond rapidly to manual correction.”


In school we learn the theoretical aspect of the shift, but when you see your first patient that is shifted the though process immediately goes to a mixture of “oh shit and piss on yourself excitement”. The shift can be extremely painful and students, if not treating this in a clinical, may not be prepared for a patient in a true 10/10 pain status. After so many years in practice, it is just another puzzle to solve now. The excitement has gone away and lucky for the patients, so has the “oh shit” response.  


Patients come into the clinic “crooked”. Scott Herbowy once said it is like looking around the corner to see if the dog is hiding.  


2. “…prevalence of LLS is difficult to establish, but estimates range from 5.6 to 80% of patient with low back pain (LBP).


This statistic is so far away from informative, that it shows that it is present in any where from 5-80 out of 100 patients with back pain. I don’t see it in 80% of the patients, but 5% may be more applicable to my population in the clinic.


3. “Lumbar spinal fusion, perhaps the most invasive of these (surgical) procedures, is increasingly common in the United States. However, its effectiveness is questionable…”


If you are going to have a fusion, go so someone that is either certified or diplomaed in MDT first. Some things can’t be undone, and this is one of those things. Make sure that there are no other options of getting relief prior to undergoing something that may not be effective and can not be undone.


4. This article is a case study of a patient that has a lateral shift deformity in the presence of an “X-stop” device, which is typically used to prevent lumbar extension in the case of spinal stenosis. The patient centralized with side gliding mobilizations and was issued side gliding against the wall in order to close the affected side. The patient responded well to this motion within the initial 4 visits and the final 4 visits were used to improve functional performance without the return of the lateral shift. The X-stop makes this case interesting because typically patients that are post-surgical are excluded from most research.  


5. “The rapid centralization of symptoms observed in this patient is similar to that reported in previous case reports describing a lateral shift correction. Centralization or peripheralization during repeated movement testing has been positively correlated with pain provocation during lumbar discography.


Centralization phenomenon is something that trained clinicians are looking for during examination of the spine. When noted, the results are typically great, but if the peripheralizes (opposite of centralization), then the patient’s results are typically poor, at least if it happens with all movements tested.  


First point to make from this is that if you have back pain, seek out a trained therapist in order to address your symptoms. Always start conservative before going invasive for pain based symptoms. If you have progressive weakness or have a loss of bowel and/or bladder function go the doctor immediately, but aside from this stay conservative first.  


Second, people get crooked. If the crooked is not associated with pain, it may be that the person has always been crooked. Not all crooked people need therapy.  


Excerpts taken from:


Peterson S, Hodges C. Lumbar lateral shift in a patient with interspinous device implantation: a case report. JMMT. 2016;24(4):215-222.