- Start with subjective examination (Patient interview)
- MAIN 7
- S (Severity) VAS + How does it affect your life? (Sick-leave, decreasing activity)
- In the case of Mr Hasan (7/10 + Affecting his job and golf)
- I (Irritability): Aggravating factors (Aggravating Positions, How long does it take to start and how easy
it is to alleviate)
- In the case of Mr. Hasan (Moderate). Aggravated in Driving. Takes 15-20 minutes to start. Alleviated
by lying for 5 minutes
- N (Nature): Relevant (Patient can describe it or can't?) (What's the most irritable tissue)
- Neurogenic (Radiating burning pain) vs Arthrogenic (Mechanical movement) vs Myogenic
- E/A (Easing position vs Aggravating direction)
- We need to know the position as an outcome measure (Y3ni we check if his pain and life improved in
that position after treatment)
- 24hr/P (Time dependent v Position Dependent) Position Mechanical, Time nonmechanical
- SQ Special Questions (Red Flags)
- Night sweating night pain (cancer), Is the pain bilateral and very progressively losing function
- Generic Questions (Cancer, Tumor, Infection, Systemic, Visceral)
- What
- What type of night pain does cancer create (10pm-2am)
- Severe continuous night pain regardless of position
- Night sweating
- Losing weight suddenly last month (non diet)
- Metal Taste in the tongue
- Especially in cold areas, people might get discitis
- Risk factor for septic shock
- Infection in annulus > Rupture > Nucleus Pulposus moves out
- Shoulder pain or Angina?
- Constant, continuous, not relieved with pain killers (Angina)
- Related to cardio activity like going up the stairs
- Mechanical direction related
- Vertebrobasilar insufficincies Questions (For neck and upper Quadrant)↓
- 5 Ds
- Diplopia
- Dysarthria
- Dysphagia
- Dizziness
- Drop Attacks
- Naseua
- Nystagmus
- Night Pain
- Myolopathies
- Bilateral arm symptoms
- Progressing quickly everyday
- losing fine movements
-
- Lower Quadrant Special Questions
- Cauda Equina :
- Bladder Bowel Function
- Saddle Anesthesia
- Progressive Bilateral Loss of Foot function
- Knee Questions
- True locking (Stuck in extension and cant move it)
- True giveaways (actual collapsing and falling)
- How would High Severity and Irritability affect my physical exam?
- Start from unload position
- Start from functional position if low severity irritability
- PHYSICAL EXAM
- AROM (Pain, Quality, Irritation)
- Assess all ROM of joint
- Draw AROM
- PROM (To differentiate between joint or muscular)
- When you find the painful rom spot > touch the pain and go back #oscillate
- This decreases fear from that direction
- By going thru the nonpainful range, we activate mechanoreceptors which decreases pain
- RMT (Repeated movement testing)
- Benefits of RMT
- We can deduce an exercise
- Pain decreased
- Increase in ROM
- Pain goes from peripheralized>centralized
- Neural Tension Testing
- Maximum tension on nerve
- Axonoplasm? What might irritate the mobility of the nerve?→Juice around the nerve. If no proper
movement, axonoplasm remains and there is a higher nociceptor concentration. Immobilty and
neighbours (muscules, joint) are tensioning the neural tissue. Ex: If shoulder is out of the neutral
position, nerves flowing from there can be affected. Hamstrings and sciatic nerve.
- What causes NTT issues usually?
- Immobility, so axonoplasm doesn't refresh
- If we have a peripheral issue, we need to check its central connection. Ex. Check neck if you have
shoulder issues.
- Radial (im a waiter that waits for my tips, arm behind body)
- Median
- Ulnar
- How is the Thoracic Spine related to the neck ?
- The TRIANGLE
- CERVICAL : SHOULDER : THORACIC
- When assessing the neck ROM
- Assess in upright posture, because slouched posture affects ROM
- Extension and Retraction
- First retract mid range then extend
- MEDIAN v ULNAR v RADIAL (Active v Passive)
-
- Ways of Spinally slacking and reducing tension/flossing
- Retraction
- Extension
- Retraction mid + Extension
- Parallel head movement to sides
- Patient lies supine
- Fash5a forward to support arm
- Shoulder depression with fist
- Abduct the shoulder
- Pronate or supinate
- Externally rotate
- Extend or Flex Elbow
- Then Wrist
- Biceps around patients head, rotate then c shaped thrust on spinous process (For rotation, stand in
front diagonal of patient)
- Joystick my arm on patients shoulder, side bend and translate spinous process to other side
- Prone on elbows and extension of spine (one hand stabilizes from front without stressing and one hand
pushes spine)
- Sitting bend forward and sleep on hands OR both hands on ears
- Lifting the latissimus by scooping it not by carrying it then rotating
- Sidelying, stabilize with one hand, and rotate spine gently
- Mobilizer vs Stabilizer Muscles?
- MOBILIZER
- Large Bulky
- Biarticular
- Fast motor
- ROM + strength + high threshold activities
- Phasic
- Fatigueable
- STABILIZERs (LOCAL vs GLOBAL)
- Local
- Deep, mono-articular, slow twitch muscle f,
- Non-direction specific (work in all directions)
- Anti- (maintains neutral position)
- Prevent local translation of joint
- Tonic (work all the time)
- Create 'physiological stiffness' of joint in dynamic situations (Maintaining joint in neutral position in
sit of movement)
- PSOAS, MUTLIFIDUS, UPPER TRAPS (keep neutral position of neck and shoulder)
- Global Stabilizers
- Concentric movement
- Isometric Hold
- Eccentric control thru range (Decelerators)
- Glutes Max has 3 fiber types
- Deep Glut max global stabilizer
- Mid Glut Max local
- Superficial mobilizer
- Relevance of mobilizers and stabilizers
- When stabilizers are inhibited, mobilizers have to do dual work (Mobilize ve Stabilize) so they
overwork
- When stabilizers are inhibited, restrictions will start > Compensations will happen > Uncontrolled
movement > Pathology (overwork of muscle for ex) > Pain and injury
- What should we do in the case mentioned?
- Inhibit mobilizer and activate the inhibited stabilizer
- Ex. Abducting and activating glutes when squatting
- Pain, injury, trauma, sustained position out of neutral, injuries w surgeries
- Paul Hodges
- Deborah Fallah
- Mark
- Mobilizer (moves the joint) Local Stab (keeps joint in neutral) Global Stab (Maintains isometric and
eccentric)
- Motor Smudge ???????
- To have multiple movement options we must have healthy muscle synergies
- QL is a global mobilizer and global stabilizer (in particular the lower part when we side bend, it keeps
the pelvis neutral)
[7:53 PM, 9/19/2023] Hassan Hijazi: - Anterior Tipping of the shoulder > more neural connection >
- What compensations might happen in elbow control issues?↓
- Some patients have can't control the elbow movement or the end range is painful, so we have
shoulder shrug compensation
- Elbow mobilizations
- Wrist Mobilizations
-
-
- Anterior then Posterior Pelvic Tilt to find Neutral
- CMCT Control Test between Lower Back and Hip ? Q
- A tighter hamstrings will pull the pelvis downward in lumbar flexion ?
- Slacken the hamstrings by slight flexion of knees, then anterior posterior pelvic tilt
- THE CMCT for Lumbar Spine
- MAIN IDEA: Moving Hip and Knee (LE in general) while keeping the Lumbar Spine and Pelvis in Neutral
Position
- The MAIN PROBLEM: Hamstrings are tight, so in neighboring movements, they pull the pelvis and ruin
neutral position
- Position 1:
- Put the Pressure Cuff (40 mmHG) under his spine (Supine)
- then Raise legs (knees flexed) without altering spine movement
- Position 2:
- Sitting Down
- Bring Pelvis Neutral Position
- Then Flex and Extend Knee in Pelvis Neutral
- Position 3:
- Standing Straight
- Bring Pelvis Neutral Position
- Then Do a deadlift (Flex Hips without changing Pelvis)
- Position 4:
- Against The Wall
- Bring Pelvis Neutral Position
- Squat without Changing Pelvis
- Position 5:
- Quadruped
- Bring Pelvis Neutral Position
- Then put bottle for tactile cue
- Extend and Flex Knee without changing Pelvis
- SIJ Mobilizations
- a. Stabilize the Ilium with one hand and mobilize the sacrum from front (Patient is prone lying)
- b. Stabilize pelvis/near spine mobilize ilium/near asis up down
- If patient cannot sleep prone, then we give sidelying
- Pain in lumbar flexion, then we mobilize SIJ posterior
- Quarduped
- One hand from down on ASIS other on ischial tuberosity (Flexion > Anterior) (Extension > Posterior)
-
- Remember when patient is irritable and severe, then use unloaded position
- SPINAL STENOSIS PATIENT (Page 44)
- Spinal Stenosis patients usually prefer flexion and hate extension, because flexion tensions the dura.
- Irreversible nonmechanical
- Bilateral symptoms.
- Neural Glides
- A/P Glides/Mobilizations of Pelvis
- Options of movement for this patient?
- Hip and Thoracic Spine
- Ex. Grade 3 Spondylolithesis Triathlon
- Multifidus Superficial G.S
- Deep Multifidus L.S (Stiffens to make sure spine is on the same level when we move)
- L.Ss usually don't have fatty substances. When they get fatty infiltration, they lose ability to stiffen.
- SPONDYLOLITHESIS
- We need to activate the Deep Multifidus (For Local Stabilizers)
- Local Stabilizers: T.A ,Pelvic Floor, Diaphragm
- Gentle Neural Glide + Control + New Options
- Calm down and control lumbal spine movement for 12 weeks (Duration for healing of sequestration
- After 12 weeks, lumbal spine exercises
- Why no to traction in Sequestration
- Muscle Guarding and Inhibition of Local Stabilizers. Over-activating mobilizers.
- A lot of mobility is not good for calming down.
[7:54 PM, 9/19/2023] Hassan Hijazi: - Wearing Sling can cause
- Axonoplasm to not refresh and thus cause neural symptoms.
- STEP 1 LISTEN
- STEP 2 RED FLAG SCREENING (Fracture, Cancer, Viscera like Angina, Dislocations)
- STEP 3 The HOLY TRIANGLE
- What courses can I take in America?
- Local stabilizer for neck shoulder > Deep Neck Flexors and Upper Traps
- What's all that can go wrong with the shoulder?
- Frozen , Impingement, Tendinopathy, Dislocation, Fracture, Labrum, Myofasyal, Bursitis, TOS
- All go under:
- PAIN LIMITATION CONTROL TRIANGLE + BIOPYSCHOSOCIAL + TENDON
- Research TOS
- Movement Health
- A CVV
- Awareness
- CNS MS Control
- Varied Intensity and Variability of Choices
-
- What causes Movement Impairments? (The process)↓
- Restriction > Compensation > Uncontrolled Movement > Symptoms
- Research Stabilizers Mobilizers Local Global
- Local Stabilizers:
- Deep, Slow Motor Units. Neutral Position and Anticapatory activation to prevent translation
- Non-direction specific
- MIVC Isometric Vol. Contr.
- Dynamic System Theory
- Compensation > UCM > Overpull direction causes articular damage v Underpull causes strain to
ligaments and labrum
- Common GH Compensations or Abnormalities
- Anterior Posterior Translation
- Internal Rotation
- Inferior Translation
- If I have lack of extensibility in my Lats
- The shoulder in GH Flex 90* will go to Internal Rotation Compensation
- Research compensations in the shoulder
- Protraction Retraction controlled by Serratus Anterior
- Ovrehead activities lower traps
- Test for Lower Traps
- Prone
- Bring Hand Near Head in V position
- Retraction/Downward Rotation without involving GHj
- Test for Traps (Middle Fibers)
- Prone
- 90* 90*
- Scapular Retraction without involving things like ER or Shoulder posterior
- Test for posterior deltoid
- One arm on bed and bend towards bed
- Go to 90* 90* Abduction of other arm
- Compenstions
- Trunk Lateral Flexion, Shoulder/Scapular Elevation
- Test for Latissimus Dorsi
- Standing
- Flex to 90 normal
- Then Continue range with external rotation
- Possible compensation: Forward Head,
- Test for Rhomboids
- Start in Can position
- Completely cross both arms to opp side
- Possible compensations: Thorax Flexion, Shoulder Extension, Downward Rotation
- Test for Subscapularis
- Patient in Supine + Towel Under the Hand for equal level
- Relocate humeral head posteriorly
- Subscapularis not working well if shoulder pops back
- Test for Serratus Anterior
- Quadruped
- Bring Thorax to neutral by thorax flexion then extension (bird dog)
- Test is to bring sternum inside without involving Thorax
[7:54 PM, 9/19/2023] Hassan Hijazi: -
- Hip Mobilizations:
- A/P Find greater trochanter in knee flexion + internal rotation > Press Down on It
- M/L
- Mobilize + Move
- Hip Abduction ROM (Isolated)
- Patient Sidelying > Knees Flexed > Carry Leg and Abduct until pelvis compensates
- Hip Extension ROM
- Same as above but extend
- How to test Internal External Rotation of Hip in Loaded position?
- Patient standing on one leg
- His hands resting on me
- Twist and dance with the patient
- Main
- What happens when we have inhibited glutes?
- Dynamic Valgus of the Knee
- Tibial External Rotation
- Ankle Eversion
- Meniscus Issues
- Ankle Sprains
- Hamstring Strain
- Adductor Strain
- Tendinopathy
- Shin Splints
- Patellar Maltracking
- TESTING
- Sidelying (Clamshell without pelvic compensation)
- Test active then compare with passive range
- If increase in passive range> then problem is myogenic (control issue) probably and not arthrogenic.
- Benchmark is 45* of clamshell
- Exercises for Hip Neutrality and Control
- 1- Patient is supine lying. Theraband around hips for neutral position maintainment. Flex and Extend leg
on ball without losing neutral.
- 2- Patient is standing. Theraband around targeted knee. Patient single leg squats and the theraband
pulls knee to neutral.
- 3- Patient side-lying. Hold leg in 90* abducted, stabilize pelvis.
- 4- Patient side-lying. Kick back on ball against wall in behind
- 5- Patient supine lying. Pillow under the glutes and bridge.
- 6- Patient quadruped. Theraband around hips. Clamshell.
- 7- Patient prone OR Quadruped. Donkeykicks.
- 8- Patient Standing. Plate under right foot. Abduct adduct OR Flex Extend, with theraband maintaining
other knee in neutral.
- 9- Supine. Ball under legs. Bridge with theraband around hips (do not open the theraband)
- 10- Side-stepping with theraband
- 11- (FOR HIGHLY IRRITABLE PATIENTS) Sitting on swiss ball. Theraband around hips. Tension band and
go back.
- Case Page 61
- Mechanical Shifts and Sudden Increase of Exercise and Activity is a cue for
- Tendinopathies
- Patellar mobilizations
- Stabilize one of the borders
- Push up or down with the other hand
- Knee Mobilizations
- A/P
- MedioLateral:
- Knee Flexed > Stabilize Femur and Push from Tibia
- Medial ROTATION of Knee
- Start from Knee Flexion > Stabilize Femur (with elbow) Tibia and Fibula> Medial Rotation then Flexion
of Knee
- OR
- One hand's biceps fully around leg and catch tibia
- with other hand externally rotate then flex leg
- A/P Knee Mobilization Prone
- Stabilize Femur > Push Tibia Up
- For common peroneal nerve irritation
- Prone> Semiflexed Knee then throw it on the other leg > Stabilize Femur > Cup Fibula > A/P Glide OR
Push with Both Thumbs
- Knee A/P Alternative
- Knee Flexed
- Hand Web (one on femur one on tibia and push on tibia)
- For Lumbar Spine Pain and Case Page 68 Case 3, what alternative movements can we teach?↓
- Bend with thoracic spine and cervical and neutralize lumbar
- Proximal Control Ex
- Control of Knee in Squat and Lunge
