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Course Title:Using a clinically reasoned, eclectic manual therapy approach in combination with cognitive functional therapy to treat low back pain.Brief Resume or?Curriculum vitae (CV):I graduated physical therapy school in 2008 from UTHSC. I then moved to Seattle, WA to pursue post graduate training with the North American Institute of Orthopedic Manual Therapy while working full time at an outpatient spine and sports medicine specialty clinic. I became OCS certified in 2011, COMT certified in 2013, and finished my orthopedic manual therapy fellowship reaching fellowship status with AAOMPT in 2014. I have been dry needling since 2015. I was introduced to Cognitive Functional Therapy and Peter O’Sullivan in 2015.I moved back to my hometown in Memphis, TN in 2014 due to a growing family of 4 kids. I have worked at Results Physiotherapy and Campbell Clinic. While at these different clinics, I have had the opportunity to be involved in their strong mentoring programs while being mentored and challenged myself by the therapists I have had the pleasure to treat along side on a daily basis. I then started my own side business, 901 Physical Therapy, in September of last year and was able to transition to full time in April. I have since grown by adding 1 other full time therapist September 1st.Course Objectives/Clinical Relevance:To understand the importance and usefulness of combining different manual therapy approaches to treat low back pain.More importantly, to be able to clinically decide when to use different manual approaches for different lumbar related diagnoses.To be able to perform manual techniques for different clinical scenarios including: lumbar extension mobilization, Maitland PA mobilization, trigger point release, specific traction, and lumbar flexion mobilization.To be able to provide 1-2 key movements to give each patient in the clinical scenarios described above. For example - extension bias, stabilization bias, flexion bias, etc. To be able to apply key aspects of cognitive functional therapy in the treatment of low back pain, especially when utilizing manual therapy. Intro - what this class is aboutClinical reasoning exercise to address different case scenarios of patients with LBP and how to reason which manual technique (and prescriptive exercises) I have found helpful to use for each case.All of this with using appropriate language and communication with our patient with a cognitive functional treatment approach foundationWe will go through several of the manual techniques but the most benefit in my humble opinion is the clinical reasoning.CaveatsVery few things I share tonight do I hold with a tight fist but am staying open! Let’s embrace the gray!Feel to disagree or call bullshitI may cuss a few timesKey Principles I use for my clinical reasoningType of painInflammatory pain and acute A-delta pain - there should be a mechanism of injury (one time incident or pattern of recent overuse)My favorite tests - History, Slump test and standing AROMSomatic (polymodal C fiber) referred pain – maybe no recent MOIMy favorite tests - History, Slump test and standing AROM, palpationHodgepodge of pain (my words!) making it difficult to assign a tissue specific cause - somatic referred, inflammatory, cognitive influences, fear/stress related pain, diet, sleep influences, diet – need to wade through it!Pain dominant vs Stiff dominantMy favorite tests - History, Slump test, standing AROMWill sometimes categorize these as fear avoidant or confidentfavorite tests for this - history, standing AROM“Lifespan of the lumbar spine dysfunction” - my own loose organization of LBP digressions that helps guide my use of the lumbar classification systemSit on our butts in school - maybe starts the dysfunctional process of key muscle/postural inhibition and early mild degenerative changes, especially if pars injury20-45 y.o.: Disc injury - pain with bending over, lifting, sitting, stiff in morningDisc injury with nerve root involvement (radiculopathy) or without30-65 y.o.: “all the mess in the middle” - myofascial pain, trigger points, postural weakness, “instability”, facet pain, DJD/DDD starting to develop, poor beliefs about back b/c keeps going out on them - pain with prolonged anything (sit, stand, walk, etc); somatic referred pain and NOT radicular pain.Telephone pole/guide wire example - i.e. lives at extremes (not in neutral zone)55-85 y.o.: stenosis - mainly leg pain and minimal LBP (just stiff) - pain in the LEG with walking that goes away with sitting (DJD/DDD stiffens spine up and “stabilizes” it - so no LBP).Stenosis causing ischemic leg pain or neuritis (radicular) leg painBrief Cognitive Functional Therapy introI first came upon this at an AAOMPT conference in 2015 and listened to Peter O’Sullivan speak. It significantly influenced me, challenged me, and changed the way I communicate with patients.Brief definition: “CFT is a patient centered approach to management that targets the beliefs, fears, and associated behaviors (both movement and lifestyle) of each individual with back pain.”Cycle of pain and disability can be fuelled by a nervous systems that is stressed and sensitized due to negative beliefs, fears, lost hope, anxiety and avoidance, linked to mal-adaptive (provocative) movement and lifestyle behabiors.Emphasis on listening to the patient’s story using a motivational interviewing approachListen for “stinkin thinkin” (body schema distortions) and address itSeeks to increase confidence and decrease fear in a patient’s view of themselves and their pain and their bodies.Seeks to correct these above issues – i.e. correct the maladaptive movement behabiors CFT fits right into the growing movement of pain science study (Lorimer Moseley and David Butler key researchers)33 y.o. male, office worker with acute low back and radiating right leg pain - direct accessHistoryPain with lifting injury – helping his friends move. Localized pain at first but tight as the day went on. Then woke up in the morning with intense pain. Pain with bending over, pain with sitting that then travels into right posterior/lateral thigh. Pain with cough/sneeze. Very stiff and painful first thing in the morning.He saw his MD who gave him muscle relaxersExaminationObservation: patient walks with forward bent posture and antalgic/splinted; sits with needing to constantly shift and can’t lean forward. Sit to stand performed with very erect posture.Lumbar AROM: flexion 40% with 8/10 LBP and leg pain. Ext 50% and stiff w/ central low back pressure. L SB 50% with right leg pain. R SB 50% with localized LBP.Neuro screen: fatigueable weakness right ankle plantarflexion with MMT (EHL,FHL,Ankle DF,ever all 5/5)Key Special Tests: Slump test + (doesn’t want to extend knee at all; looking down worsens pain significantly - i.e. an OBVIOUS positive); SLR + at 30 degrees.Palpation - very tender at L5 with CPADiagnosisTreatmentCognitive Functional Treatment influence63 y.o. blue collar worker with acute right anterior/lateral thigh pain – referred by MDHistory1 week ago after lifting a 20# box into a truck he started walking and had sharp pain right anterior proximal thigh and could barely walk secondary to pain. He walked bent over. Pain spread to knee next day. Next morning extremely painful and couldn’t move well or walk. Saw MD and given steroid dose pack that helped a little but now flared back up again 1 week later and referred to PT. Patient feels better with sitting but still can’t stand up straight to walk due to right anterior thigh pain.ExaminationObservation: sit to stand very antalgic, walks bent over significantly, sits with back straighter and right leg straight.Lumbar AROM: flexion full no pain, ext lacks 20% to neutral (i.e. bad!!), Bilat SB 50% and increases his sharp pain in thighSpecial tests: Slump negative; can’t lay supine or prone for SLRNeuro screen: Quad reflex 3+, quad MMT 4+/5 on R (5/5 on L)ROM in SL: can’t passively move hip to neutral - stuck at about 10 degrees shy, especially if bending knee (i.e. + femoral nerve test)Palpation in sidelying: TTP L2,L3,L4 and UPA to L3/4 increases his pain. Too guarded to discern hypomobility.DiagnosisTreatmentCognitive Functional Treatment Influence72 y.o. Male with 9 month history of right antero-lateral thigh pain seen prior by MD - direct accessHistorySaw MD 2 months. X-rays taken showing DJD/DDD throughout; MRI showing disc bulges and given dose pack with no change and then had L5 injection with no change. Right anterior thigh pain gradually increasing past 9 months. In the past 4-5 months it is really bothering him so saw MD with treatment but no change and now can’t stand to walk for more than 10 minutes before it becomes very achy and he must sit down. When he sits he feels fine. If he rests for 5 minutes it goes away and he can continue. No low back pain.ExaminationObservation: Walks with normal "old man stiff gait" but nothing out of ordinary and nothing antalgicLumbar AROM: Flexion 75% with on pain, extension 30% with no pain at first, L SB 50% no pain, R SB 50% no pain but bends in flexion quadrant, Holding extension + R SB brings on his symptoms within 8-10 seconds.Special Tests: neg slump, SLR, femoral nerve test; Negative FABERNeuro screen: negativeHip ROM: bilat hips same with expected stiffness but nothing significant or symptomaticMMT: R quads 4+/5, bilat hip abd and ext 4-/5Palpation: nothing reproduced his symptoms with lumbar PA, Lsp/hip/thigh muscle palpationDiagnosisTreatmentCognitive Functional Treatment Influence42 y.o. female cross fit athlete with approx 1 year hx of lower back and right leg pain and “heaviness” - direct accessHistoryLong history of LBP as active individual in Cross-fit. Then had increasing right leg pain and heaviness 1 year ago. MRI – disc bulge. Treatment – injection with great relief. However, in the past 8-9 months, she’s still had LBP with prolonged walking and activity. She also has pain with sitting for 2 hours in car, tightness first thing in the morning, and pain/pressure with lighter squat workout (worked up to 90# but is scared of reinjury) and LBP with box jumps.none of these symptoms last very long once she changes positions.As a side note, she is starting to get hip tightness/pinch with squat.ExaminationObservation: nothing stands out with gait and sitting/standing postureLumbar AROM: palms to floor, ext 70% with central LBP, L ext quadrant 50% and sore, R SB/Ext 80% no pain.Special tests: slump negative, SLR negative, L hip flexion/scour causes “pinch”, L figure 4 = 20 degrees limited (R was WNL)Palpation: + CPA L5 and + UPA L4/5 L and R.MMT: Glut med bilat 4-/5, L hip ER 4+/5, all others 5/5DiagnosisTreatmentCognitive Functional Treatment Influence?64 y.o. female with right hip and lateral leg pain - direct accessHistory4 weeks hx of gradual increasing right postero-lateral hip pain that now extends past knee down lateral lower leg to foot. Started off with pain when first moving in the morning and at the end of the day but then has steadily gotten worse. Now it’s keep her up at night and there is pain with any amount of walking (within first minute of walking). Pain is really strong into the leg and lower leg.ExaminationObservation: walks in with limp, avoiding weight bearing on right. Also sits off to the left to avoid pressure on right hip.Lumbar AROM: flexion 50% with catching into hip and thigh. Extension 80% with some pulling into hip. L SB full and no pain, R SB 75% and pulling into hip.Special tests: Slump test negative. Single leg stance – her pain and couldn’t hold it.Joint ROM: right hip flexion 80 deg and her pain in butt. Hip ER and IR guarded and painful.MMT: hip abduction MMT immediate pain and can’t holdPalpation: prone lumbar CPA/UPA negative (and whatever else I could think of to stress Lsp all negative!)Hip Palpation – her pain with glut med/minimus and refers down her lateral entire leg.DiagnosisTreatmentCognitive Functional Treatment Influence32 y.o. active male with 5 year history of surgical intervention due to LBP and right posterolateral leg pain — referred by MD who performed recent injectionsHistoryDisc injury 5 years ago - surgery within 4 months after failed PT. He did well for a few years, though still had low level pain. He then had flare ups on two different occasions with return of symptoms - tried injections w/ some improvement but would still flare up and still daily LBP and right leg pain. Eventually had Left L3, L4, L5 medial branch nerve ablation. Better but pain still 6/10 so referred for PT 2 months after this procedure..Aggravants: pain with sitting at work >30’, long car rides (loves to travel with family), pain with lifting kids, doing yard work; nervous to play golf or try running; p!/fear with picking up around houseExaminationObservation: nothing stands out with gait; adapts “extension” posture in L-spine (i.e. standing from chair, squatting, etc).Lumbar AROM: Flexion 75% with no posterior hip mvt (guarded, no lumbar flexion) with lumbar pull; ext 60% with 5/10 pain (his spot) right low back, R SB 75% stiff; L SB and bilat rot all 90% no sx (so really, his movement wasn’t too bad!)Tsp PROM: L and R SB 70%, Rot 80%.Special Tests: SLR negative but tight (R2 60 deg R and 70 deg L); Slump test – 80% knee extension and negative for inflammation but some tightness increases with chin tuck (neural tension)Palpation: No pain with PA’s throughout L-sp...except right T12, L1, L2 UPA’s.TTP to the glut med, min, max, piriformis, TFL, psoas, erector spinal (i.e. what’s not tender??)MMT: hip abd 4-/5 right, 4/5 left; bilat hip flexion and hip ER 4/5, all others 5/5 DiagnosisTreatmentCognitive Functional Treatment InfluenceReferences:Clinical and Radiological Anatomy of the Lumbar Spine. 5th Edition. N. Bogduk.Manipulative Thrust Techniques. Erl PettmanMyofascial Pain and Dysfunction: The Trigger Point Manual. Travell and Simons.AAOMPT conference breakout classes and key lectures from Peter O’Sullivan.Continuing Education course manuals and class instructors and fellowship mentors primarily from NAIOMT. Also from Maitland, Myopain, etc.Amazing clinicians I’ve learned from across the years from Olympic Physical Therapy, Campbell Clinic, Results Physiotherapy, Rehab Etc, Peak Potential Physiotherapy, etc! (I know this is not a true reference – but I think it counts!) ................
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