Upper Quarter: Smooth Sailing, Lower Quarter: A Storm is Coming! | Modern Manual Therapy Blog

Upper Quarter: Smooth Sailing, Lower Quarter: A Storm is Coming!

I was excited to blog about a case that I thought would be a piece of cake treatment wise, but interesting from a story standpoint. It ended up being more interesting than I thought and required quite a bit of patient education.

The initial blog post that I did not get around to writing was going to be called "threat-less." The patient is a patient in late 40s who was referred by her dentist for a lack of ROM in her mandible. It had progressed to a point where she had only 17 mm of mandible depression and her dentist could no longer treat or clean. She had NO pain, only tightness, and she only knew about it because her dentist mentioned it repeatedly.

When asked about past medical history, she said 20+ years ago, she was in an MVA and her head went through the windshield. She said this with a casual smile on her face and my intern and I spoke about it later. I noted how she spoke about it as if one may recall stubbing a toe. It was literally the most threat-less perception of major head/neck trauma I had ever heard in 15 years of practice.

She understandably had not only lack of mandible depression, but close to B frozen shoulder, and about 5 degrees of cervical motion in all planes. If she had any instability, it was long gone, and replaced with major multi-directional dysfunction. The motion loss was also present in NWB, and the battery of upper cervical stability tests were negative for what that is worth.

After some light IASTM to masseter patterns and some thumb halfway on top of her molars, her depression improved to where I could fit my entire thumb on both sides. I remarked that unless my thumb just shrunk, we made some progress!

We did some light tissue work to her cervical spine and she was instructed on cervical disassociation exercises and self TMJ distraction. Like most slow responders, that need true changes in joints/tissues, she noticed changes in ROM slowly over a few weeks in her cervical spine greater than her mandible. Then one day, I heard another PT ask her if she needed a bolster under her LEs while she was lying on heat (my SOAP time).

I instantly came out and asked her what was wrong. She stated her back hurt, and I asked when it started. She replied that she had chronic back pain for 10-15 years and had lumbar surgery. She did not write this or indicate it when I asked about any other medical history relevant or not. She had a laminectomy and "constant" pain. When asked about her previous 3 treatments, she stated not mentioning it, because she thought nothing could be done about it and she was "used to it." She also felt that it was worth increasing her mandible ROM. My education consisted of threat perception and comparing apples to oranges
  • you have no pain/complaints in your upper body and your head was in a windshield 
  • you have persistent pain in your lower back and you had a controlled surgery
    • damage therefore does not equal pain
I educated her about threat perception, the CNS alarm system, etc, and gave her some MDT strategies to alleviate her LBP. During this talk, she was almost on the verge of tears because she was so emotionally attached to the pain in her lumbar spine. This was just a severe contrast to what had happened to her head and neck that I found it compelling. What are your thoughts on this?

Keeping it Eclectic one day at a time!


  1. Before you mentioned it I had not heard of the NCS alarm system nor threat perception. Can you write a post about this or send some links on info. I treat a caseload of patients with TMD and chronic pelvic pain and see education as just especially important for these folks.

  2. Grant, I recommend Explain Pain, and Why Do I Hurt? Two texts that can be read by patients but in conjunction with modern pain science education, that has been research extensively to reduce perceived threat and thus help to decrease CNS sensitivity. Link to Why Do I Hurt http://astore.amazon.com/themanuther-20/detail/0985718625

    and Explain Pain http://astore.amazon.com/themanuther-20/detail/097509100X

    Also be sure to read Body in Mind, and check out Lorimer Moseley's lectures on movementlectures.com and on youtube.

  3. Thank you! After dragging my feet I will order them now. I have been following Mosley and Lowe with ISPI for some time now. For those of you out there interested in the importance of the education piece, I hear great things about ISPI ConEd.

  4. It would be interesting to use a Mcgill pain questionnaire with this patient. For those who have not heard of this outcome measure, it is intended to measure the patient's emotional relationship/perception of their pain. I would be curious to know where she stands on this scale.

    Thank you for your posts!

  5. You're right, it would be interesting, but she would actually have to do two pain questionnaires as she is very much high fear avoidance LQ and none at all for UQ.