Improving Your Junctions' Function: Utilizing clinical decision making with refining techniques of HVLAT for comfort and effectiveness

Alec Kay, PT, MSPT, DMT, ATC, OCS, FAAOMPT Brian Power, PT, DPT, DMT, FAAOMPT

2105 AAOMPT Conference – Louisville, KY Sunday, October 25, 2015

INTRODUCTION:

Alec Kay – PT, MSPT, DMT, ATC, OCS, FAAOMPT Alec received a Bachelors of Science in Exercise Physiology and was Certified as an Athletic Trainer in 1988 at the University of California, Davis. He was awarded a Masters of Science in Physical Therapy from the University of the Pacific in 1990. His additional post-graduate studies included completion of a Master of Orthopedic Manual Therapy in 1997 and a Doctor of Manual Therapy degree in 2000 from the Ola Grimsby Institute. Alec is currently teaching advanced techniques in manual therapy in the states as well as in Europe.

Brian Power – PT, DPT, DMT, FAAOMPT Brian received a Bachelors of Science in Community Health in 1984. He then graduated from the University of Puget Sound in 1988 with a Bachelors of Science in Physical Therapy. He completed a four-year post-graduate program in Manual Therapy from the Ola Grimsby Institute in 1995. Brian was awarded a Doctor of Manual Therapy degree in 2005. Brian teaches post-graduate courses in manual therapy in the states and in Europe and Asia.

SCHEDULE:

8.00 – Introduction 8.05 – Cervico-Thoracic indications and technique 8.15 – Upper Rib indications and technique 8.25 – Mid/Lower Rib indications and technique 8.35 – Thoraco-Lumbar indications and technique 8.45 – Lumbo-Sacral indications and technique 8.55 - Close

Components of an OMT Examination www.olagrimsby.com ! Positional testing ! Palpation of the Carotid Artery ! Neurological examination ! Craniovertebral ligament testing ! Blood pressure ! Differentiation ! Refer on for further investigation ! Additional training

unlock your future IFOMPT Cs Exam Guidelines 2012

IFOMPT Cervical Manipulation Survey www.olagrimsby.com All of the 20 member countries responded and recommended: • Use of sustained pre-manipulation position hold • Performance of craniovertebral ligament stress tests • Dizziness differentiation test • Hautant’s test unlock your future Carlesso and Rivett 2007

Examination / Risk www.olagrimsby.com

1. Initial Observation 2. History/Interview 3. Structural Inspection 4. Active Movements 5. Passive Movements 6. Resisted Movements X 3 7. Palpation 8. Neurological Examination 9. Specific Mobility Tests and Positional Faults 10. Specific Regional Tests 11. Additional Test (MRI, x-ray, etc.) 12. Correlation 13. Treatment 14. Prognosis

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CONTRAINDICATIONS FOR SPINAL MANIPULATIVE THERAPY The following list of contraindications for spinal manipulative therapy was updated and adapted from Kleyhans AM, Terret AGJ, The prevention of complications from spinal manipulative Therapy, Aspects of Manipulative Therapy, 161-174

ABSOLUTE: Articular derangements: References: 1. Acute arthritis of any kind 9, 11, 13, 14, 18, 23, 24, 35, 38 2. RA with instability or acute 4, 9, 10, 11, 18, 23, 35, 38 3. Ankylosing —acute 2, 8, 9, 10, 11, 13, 14, 18, 27, 35 4. Dislocation 9, 15, 36 5. Hypermobility of segment 9, 10, 11, 21, 24, 35 6. Ruptured ligaments 9, 35 7. Trauma of recent occurrence--whiplash 9, 35 8. Advanced degenerative changes 11 9. Congenital generalized hypermobility (Ehlers-Danlos syndrome) 11

Bone weakening and destructive disease: References: 1. Calve's disease 22 2. Fracture 9, 15, 23, 27, 29, 34, 35 3. Malignancy/tumor (primary/secondary) 4, 9, 10, 11, 13, 23, 24, 27, 35, 36 4. Osteomalcia 10, 11, 13, 22 5. Osteoporosis 2, 4, 9, 23, 27, 34, 35 6. Osteomyelitis 11, 14, 27, 33, 35 7. Tuberculosis (Pott's disease) 4, 11, 14, 23, 34, 35, 36

Circulatory disturbances: References: 1. Aneurysm 2. Anticoagulant therapy 6, 11, 13 3. Atherosclerosis 3, 13 4. Visceral arterial disease 11 5. Calcification of aorta 13

Disc lesions: References: 1. Prolapse with serious neurological changes 4, 5, 9, 10, 11, 13, 16, 17, 19, 27, 28, 35 2. Evidence of more than one spinal nerve root on one side 11 3. Cervical or thoracic joint conditions causing neurological signs in lower limbs 11, 13 4. Acute cervical or lumbar herniation 9 5. Thoracic herniation 9

Neurologic dysfunction: References: 1. Micturition with sacral root involvement 5, 35 2. Painful movement in all directions 23 3. Transverse myelitis 11 4. Severe root pain 11 5. Malformations of spinal cord including syringomyelia 10 Unclassified: References: 1. Infectious disease 13, 23, 27 2. Uncooperative patient or patient intolerance 10, 23 3. Advanced diabetes when tissue value may be low 11, 13 4. Undiagnosed pain 11

RELATIVE: Articular derangements: References: 1. after acute stage 2, 9, 29, 33, 35 2. Articular deformity 5, 9 3. Congenital anomalies 12, 18, 23, 32, 37, 38 4. Hypertrophic spondyloarthritis 9, 13, 33 5. Osteoarthritis - especially severe or advanced 9, 13, 35 6. Osteochondrosis 9 7. RA - subacute 13, 27, 38 8. Torticollis 5 9. Inflamed joint 13

Bone weakening and modifying disease: References: 1. Hemangioma 31, 34 2. Paget's disease 11, 22, 27, 33 3. Scheuermann's disease 1, 14, 18, 23, 27 4. / with symptoms 9, 13, 14, 33

Disc lesions: References: 1. Posterolateral and posteromedial disc protrusions 13 2. Degeneraative disease 17, 28, 35

Neurological dysfunction: References: 1. Myelopathy 5, 35 2. Non-vertebragenous pain 27, 35 3. Pyramidal tract involvement 5 4. with disc lesion 13, 35 5. Viscerosomatic reflex pain 27, 35

Unclassified: References: 1. Abdominal hernia 30 2. Asthma 1, 30 3. Dysmenorrhea 30 4. Epicondylitis 8 5. Long term steroid use 13 6. Low pain threshold 13 7. Peptic ulcer 18 8. Post spinal surgery 27 9. Pregnancy, especially first trimester 5, 13, 27, 33 10. 11, 13, 35 11. Psychogenic disorders with dependence on manual therapy 9, 13 12. Patients who have been treated recently by another practitioner 13 13. Signs and symptoms do not match 13

REGIONAL: Thoracic spine: References: 1. Scoliosis 11 2. Unilateral hemi-vertebrae 12

Lumbar spine: References: 1. Accessory sacroiliac joint 2. Baastrup's disease 12, 23 3. Cleft in sagittal plane 12 4. Facet tropism 12, 18 5. Knife clasp syndrome 6. Nuclear impression 12 7. Progressive osteoarthritis of sacroiliac joint 9 8. Pseudosacralization 12, 18 9. Sacralization, lumbarization 11, 12, 18 10. Spina bifida occulta 11, 18 11. Spondylolisthesis (neighboring segments okay) 9, 18

Bibliography 1. Beyeler W, Scheuermann's disease and its chiropractic management, Annals of Swiss Chiropractors Assoc, 1:70, 1960. 2. Bollier W, Inflammatory, infections and neoplastic disease of the lumbar spine, Annals of Swiss Chiropractors Assoc, 1960b. 3. Boshes LD, Vascular accidents associated with neck manipulation, JAMA 1652:1710, 1959. 4. Bourdillon JF, Spinal manipulation, 3rd edition, Appleton-Century-Croft, New York, 1982. 5. Cyriax J, Textbook of orthopedic medicine, vol. II, 10th edition, Balliere Tindall, London, 1980. 6. Dabbert O, Freeman DG, Weis AJ, Spinal meningeal hematome, warfarin therapy and chiropractic adjustment, JAMA 214:11, 1970. 7. Davidson KC, Weiford EC, Dixon GD, Traumatic vertebral artery pseudoaneurysm following chiropractic manipulation, Neuroradiology, 115:651, 1975. 8. Droz JM, Indications and contraindications of vertebral manipulations, Annals of Swill Chiropractors Assoc, 5:8, 1971. 9. Dvorak J, Inappropriate indications and contraindications for manual therapy, J Man Med, 6(3):85- 89, 1991. 10. Dvorak J et al, Consensus and recommendations as to the side effects and complications of manual therapy of the cervical spine, J Man Med, 6(3): 117-118, 1991. 11. Grieve GP, Common vertebral joint problems, Churchill Livingston, New York, 1981. 12. Grillo G, Anomalies of the lumbar spine, Annals of the Swiss Chiropractors Assoc, 1:56, 1960. 13. Hartman L, Handbook of Osteopathic Technique, Hutchinson, Sydney, 1985. 14. Hauberg GV, Contraindications of the manual therapy of the spine, Hippokrates, p. 231, 1967. 15. Heilig D, Whiplash – mechanics of injury, management of cervical and dorsal involvement, In: 1965 Yearbook. Academy of Applied Osteopathy, 1965. 16. Hooper J, Low and manipulation. Paraparesis after treatment of by physical methods, Medical J of Australia, 1:549-551, 1973. 17. Jaquet P, Clinical chiropractic - A study of cases, Crounauer 18. Janse J, Principles and practice of the chiropractic: an anthology, R Hildegrandt (ed), National College of Chiropractic, Lombard, Illinois, 1976. 19. Jennett WB, A study of 25 cases of compression of the cauda equina by prolapsed LVD, J Neurology, Neurosurgery, Psychiatry, 19:109, 1956. 20. Kaiser G, Orthopedics and traumatology, Beitr. Orthop., 20:581, 1973. 21. Kaltenborn FM, Manual therapy of the extremity joints, Oslo, Olaf Norlis Bokhandel, 1976. 22. Lindner H, A synopsis of the dystrophies of the lumbar spine, Annals of Swiss Chiropractic Assoc, 1:143, 1960.23. Maigne R, Orthopaedic medicine: a new approach to vertebral manipulations, Charles C. Thomas, Illinois,1972. 24. Maitland GD, Vertebral manipulation, 4th edition, Butterworth, London, 1977. 25. Mehalic T, Farhat SM, Vertebral artery injury from chiropractic manipulation, Sirg Neuro, 2:125, 1974 26. Miller RG, Burton R, Stroke following chiropractic manipulation of the spine, JAMA, 229:189, 1974 27. Nwuga VC, Manipulations of the spine, Williams and Wilkins, Baltimore, 1976. 28. Odom GL, Neck ache and back ache. Proceedings of the NINCDS Conference on Neck Ache and Back Ache, Charles C. Thomas, Illinois, 1970. 29. Rinsky LS, Reynolds GG, Jameson RM, Hamilton RD, Cervical spine cord injury after chiropractic adjustment, Paraplegia, 13:227-233, 1976. 30. Sandoz R, About some problems pertaining to the choice of indications for chiropractic theapy. Annals of the Swiss Chiropractors Assoc, 3:201, 1965. 31. Sandoz R, Presentation and discussion of a few cases of lumbo-abdominal pain, Annals of the Swiss Chiropractic Assoc, 4, 1969. 32. Sandoz R, Newer trends in the pathogenesis of spinal disorders, Annals of the Swiss Chiropractors Assoc, 5, 1960. 33. Sandoz R, Lorenz E, Presentation of an original lumbar technique, Annals of the Swiss Chiropractors Assoc, 5, 1960. 34. Siehl D, Manipulation of the spine under anaesthesia, In: 1967 Yearbook, Acad of Applied Osteopathy, 1967. 35. Stoddard A, Manual of Osteopathic Practice, Hutchinson, London, 1969. 36. Timbrell-Fisher AG, Treatment by manipulation, HK Lewis, London, 1948. 37. Valentini E, The occipito-cervical region, Annals of the Swiss Chiropractors Assoc, 4:225, 1969. 38. Yochum TR, Radiology of the arthritides, International College of Chiropractic, Melbourne, 1978

TECHNIQUE: Cervico-thoracic distraction in sitting with lift.

PT. POSITION: Sitting towards the back of the table (little kid on a big chair).

OP. POSITION: Standing behind the patient. The segment to be treated should be about mid sternum of the operator. A towel may be folded or the use of a wedge to gain more specificity.

HAND PLACEMENT: The operator’s hands reach through the arms and grab the patient’s wrists. The patient then clasps their hands behind their neck (low).

MANIP. THRUST: Respirations are felt and at the expiratory phase, the barrier is identified and a short thrust is applied to the segment. At the time of thrust, the operator adducts their arms and pulls the patient towards them; at the same time, pushes forward into the segment with the sternum.

NOTE: Be careful not to push forward with your hands causing Cs flexion or pull the patient’s arms into horizontal abduction.

TECHNIQUE: Rib supine P/A distraction (gap).

PT. POSITIION: Supine close to the edge of the table. Arms clasped together behind the neck.

OP. POSITION: Standing to the side of the patient. Operator flexes the patient to the level to be treated.

HAND PLACEMENT: The operator rotates the patient to access the ribs. One hand reaches around the patient and is placed at the rib so that the finger is touching the spinous process and the thumb is in line with the rib to be treated (salute position).The other arm is placed across the patient’s ulnas and controls the amount of flexion, side bending and rotation to isolate the barrier.

MANIP. THRUST: The operator’s arm controls the amount and direction of motion to find the barrier. A short thrust through the arms as the operator’s torso is directed to the rib perpendicular to the costo-vertebral surface.

TECHNIQUE: Mid/Lower rib distraction in sitting

PT. POSITION: Sitting on the table close to the back edge. Arms are crossed.

OP. POSITION: Standing behind the patient.

HAND PLACEMENT: Apply the near side’s hypothenar eminence to the rib head. The far side’s hand reaches around the patient.

FROM ABOVE: Operator and patient rotate away, pushing the rib forward. Sideband toward the rib and extend the rib somewhat by asking the patient to extend their head and neck.

FROM BELOW: Nothing.

MANIP. THRUST: Apply a short amplitude thrust with the pisiform vertically on the rib head. Apply a compressive force between the two hands when thrusting.

NOTE: This technique is most effective when the proper steps are followed: 1. Pisiform on rib angle and arm across body compresses into rib. 2. Rotate your body and the patient’s together away from the rib 3. At the last moment side bend toward with extension. 4. Lift vertically. You may need to get under the rib by bending your knees.

TECHNIQUE: Thoraco Lumbar P/A distraction.

PT. POSITION: Sitting toward the near side of the table with knees bent and hands clasped around the neck. Operator’s near hip is at the level of the patient’s hip.

OP. POSITION: Standing to the near side.

HAND PLACEMENT: Operator’s near hand is placed across the patient’s forearms and supports the neck on top of the clasped hands. A softly closed fist of the far hand is placed at the T/L junction (found by locating the floating ribs).

FROM ABOVE: The patient is asked to fully relax into a slightly flexed posture (table may need to be raised or already almost too high to start).

FROM BELOW: Nothing.

MANIP. THRUST: The operator takes a long step forward at the same time as the patient is lowered onto the soft fist. The operator applies a short amplitude thrust through the chest in a direction perpendicular to the joint plane.

TECHNIQUE: Seated lower thoracic or TL junction rotation manip

PT. POSITION: Seated straddling a table

OP. POSITION: Positioned so patient is high enough for therapist to be shoulder to shoulder with patient, side of the patient so rotation is toward the therapist

HAND PLACEMENT: Operator’s anterior hand across chest of patient protected with pillow or towel, under opposite axilla and on to lateral posterior thorax. Operator's posterior hand with pisiform on opposite side transvers process.

FROM ABOVE: Flexion into the segment; side bending away into the segment rotating toward the operator. FROM BELOW: Flex or extend, side bend away with neutral rotation.

MANIP. THRUST: Apply a short amplitude thrust with both hands in to rotation toward the operator

TECHNIQUE: L5 rotation with distraction.

PT. POSITION: Side lying with the head toward the foot section of the table.

OP. POSITION: Standing facing the patient.

HAND PLACEMENT: Operator’s far hand is on the patient’s lateral thigh. The near hand and forearm supports the thoracic and lumbar spine.

FROM ABOVE: Flexion into the segment; side bending into the segment by lifting the foot end of the table.

FROM BELOW: Nothing.

MANIP. THRUST: Apply a short amplitude thrust with the far hand on the lateral thigh moving L5 into rotation.