October 2011 | Modern Manual Therapy Blog

This is a follow up for HEP to be used after the patient has hamstring work done. It goes well with the corkscrew technique. As long as the patient can balance on a single limb stance, it is very effective as it is also a neurodynamic tensioner depending on how much hip adduction and IR you instruct them on. They can oscillate with repeated hip IR and ankle dorsiflexion to start, and progress to uninvolved LE squats with overpressure of inferior glide to really increase the stretch proximally and posteriorly.

via Mike Reinold

A great follow up to the hip flexion strength post from last week. Mike goes over functional assessment and exercises to enhance hip flexion. I normally use manual techniques like ITB and psoas release when the hip flexors are restricted. IASTM to the quadriceps, hamstrings, and ITB is also very effective. "Muscle" restrictions means they cannot contract or stretch. I tell my patients that adhesions are similar to spraying starch over clothing; the end result being the muscles cannot fold or stretch. When the soft tissues around the muscles are remodelled properly, the muscle often tests longer and stronger. If it still tests weak, that's when I prescribe strengthening ther ex.

via Body in Mind

BIM studied if it was possible to modulate pain with working memory. They have some interesting results. Could the response of pain to movement be because the brain cannot clear the pain related information from working memory? This could explain how individual characteristics like beliefs and worries contribute to chronic pain states.

via Physical Therapy Diagnosis

Good News Everyone! Actually not really much to say, click the link, feel immense satisfaction and all I can say is....

I thought of this technique to improve several hip common hip dysfunctions as a progression in force and treatment. It improves

  • hip IR
  • hamstring mobility
  • sciatic neurodynamics
  • SLR
Common dysfunctions this technique helps

  • recovering hamstring strain
  • peripheral neuropathic pain from sciatic entrapment
  • piriformis syndrome
  • lumbar derangement with LE complaints
  • hip capsular pattern
I use it as a end of week 2 progression, as in, if you use this on a patient too soon, it will probably be too aggressive and you've just lost a patient and a possible referral source. I will post a follow up for home program stretching later. Hope the technique helps with your patients/clients!

Interesting research here. The control group actually had rotator cuff surgery, indicating there was either injury or dysfunction leading to tear and there were still significant differences. Of note is that there are capsular changes with increased cell density and fibroblastic proliferation with the frozen shoulder group. The review does not indicate the chronicity of either group.  It's a possibility since they were undergoing arthroscopy, that the R/C tears were at most subacute.

I've never believed what the research has shown in the past about frozen shoulder spontaneously thawing within 1-2 years of onset. It may "feel" better, but how could their function return without treatment? I haven't seen it clinically, but that could also be because they got better without treatment. I find successful outcome for return to function and restoration of pain free motion is highly dependent on the patient's

  • pain tolerance (not threshold) to appropriately aggressive STM and JM
  • compliance with their home program - much more so than the manual treatment
What has your experience with frozen shoulder been?

Another lateral shift case so soon? Sometimes I goes years without seeing a true lumbar lateral shift. This year I had two in two months. The latest is a bit different than the last case.

Subjective: Pt reports chronic history of right lower lumbar pain for the past three years. She previously had treatment from another CertMDT PT in the area with good resolution, but Sx would often return. In MDT courses, they teach if the Sx return, it is the clinician's fault for not educating the patient enough in prophyaxis!

I find when a patient says provider "x" told them "y," the truth often is somewhere in between. More than likely she did not remain compliant with her old ther ex, or it is possible it was not emphasized enough she should do her HEP forever.

Her Sx were worse within the past four weeks, and she also had new complaints of left knee pain that was worsening in the past two weeks.

observations: right iliac crest moderately elevated, moderate lumbar lateral shift to the left, ambulated with antalgic gait, decreased stance time on left LE.

Repeated motions:
SGIS left WNL, painful
SGIS right sev loss, painful during motion

What's the first goal in treatment of a lateral shift patient? Correct the shift!

This went as expected after 10-15 minutes of overpressure in the lateral shift correction position, she was standing more upright, but not able to maintain the correction. I progressed her to lumbar rotation in flexion with overpressure. Rotation was trunk to the left, to close the right for far lateral derangement reduction. Several sets of this and she was walking upright, and left the clinic feeling much better. We also reviewed shift correction in a doorway for HEP and she was instructed on the use of a lumbar roll for sitting.


The patient stated on treatment 3 she was walking more upright, had much less right LBP, and wanted us to address her left knee pain. She had difficulty ambulating, and using stairs.

knee flexion

  • left 115/hard end feel
  • right WNL/soft end feel
knee extension
  • left 0/hard end feel/painful
  • right -10 (hyper) firm
myofascia: severe restrictions with tenderness to the left ITB in lengthening and transverse play
Hip IR and ER were surprisingly WNL bilaterally with firm end feels

After 7-10 minutes of left ITB TASTM and functional release plus Mulligan tibial IR mobilizations, she had near full left knee flexion, but extension was still blocked. She was able to walk with much less pain. 

She was instructed on having her husband roll her ITB with a rolling pin for 5 minutes twice a day until next follow up.


Pt continued to report much less right lower back pain, but was slightly more shifted today. Rotation in flexion (trunk to left) reduced the shift and abolished her lower back pain. TASTM was again performed to left ITB and I added transverse release, plus A/P thrust to the proximal tibia for flexion and to the distal femur for extension. Her left knee flexion and extension were WNL afterward with minimal pain at end range extension. She was prescribed repeated knee extension in open chain sitting upright. This is not normally my preferred knee loading strategy, as I normally show it in standing with overpressure, but I wanted to avoid repeated trunk flexion to avoid aggravating her lumbar derangement. 

While walking around to assess her functional improvement, I noticed her right iliac crest was still moderately elevated. Instead of testing for it, with useless tests like supine to long sit and Gilet's test, I corrected for it with some isometric manipulation or CR of the hip flexors with right LE off of the table on the right side. After 4 to 5 reps of this, and we tested walking again. The patient felt as if she was walking and WB differently,  plus her right iliac crest was no longer elevated visually or to palpation.

As a progression, I will probably add some QL and psoas release on the right side if her hip hikes again, otherwise just show her some standing hip extension stretches with self generated overpressure if it stays level.


The lateral shift, despite history of being chronic was an acute exacerbation, which explains why it was easily corrected with end range loading and unloading strategies. The patient's left knee most likely had dysfunction from increased WB over the years of repeatedly shifting to the left in standing. It was surprising how fast it returned to full flexion and almost full extension.

Here are some possibilities why the patient may have had recurrences:

  • she was never instructed on the use of a lumbar roll
  • she was performing her shift correction incorrectly
  • iliac crest rotation may not have been addressed by previous MDT only practitioner
  • she most likely has some hip hiker and flexor adaptive shortening that needs to be addressed
I will keep you updated on her progress, but 3 visits in and she is doing much better!

Day 1 and Day 2

A lot of good points summarized by Dr. Weingroff. I have read all of Sahrmann's texts and taken courses in her approach, but never heard taken a course from her peronally. I plan on doing it sometime in the future. I do believe that a clinician of Sahrmann's status can use very directed exercise at restoring correct movment patterns. I think manual therapy assists this process and makes the patient more compliant if the movement is less painful and easier to perform at home without the clinician's directions.

via Chaitow's Chat

I follow Paris' Manual Therapy Triad for treatment 1) STM 2) Joint Manipulation 3) Neuromuscular Reeducation

Part 3 can be anything from stretching, to PNF, to ther ex in the new movement plane or pattern. I think PNF is done an injustice in entry level DPT schools because most teach only in the neuro rehab courses. A colleague of mine teaching ortho at D'Youville College tells his students that EVERY patient is an orthopaedic patient. Similarly, you can use PNF on any patient needing their muscles facilitated. Paris states we shouldn't call MET by osteopathic terminology as they don't use our nomenclature for techniques. He prefers the term isometric manipulation. They're all just variations on basic PNF, whether it's hold relax or contract relax. As a new grad, I read Chaitow's newests texts at the time, which still hold up today. I am looking forward to his updates.

I only use PNF after doing STM and JM, my colleague in the clinic uses PNF to warm up his patients prior to JM. While the evidence is limited to some trials for increasing ROM in normals, it still remains an effective and pain free technique to increase ROM. I do not recommend using it isolation of other manual techniques as I found clinically that the ROM improvements did not last as long without using other techniques such as STM and JM along with it.

via Pain-Topics.org

Pain-Topics reviews another article regarding pain and exercise, this time on migraines. I see a lot of patients with the Dx "migraine" in my clinic; these cases usually turn out to be cervicogenic or tension headaches easily treated by manual therapy and exercise. Occasionally, the patients have true migraines that are unaffected by mechanical means.

Based on this article, despite the only modest effects, I am going to start prescribing more general exercise in the clinic while they're there twice a week, which only leaves them two more times to do it at home. Sometimes we get away from our roots, and since I am firmly rooted in OMPT and MDT, I sometimes forget what every PT should know... almost everyone could use more general exercise in their routine.

Dysfunction in the subscapularis can be seen in

  • shoulder impingement patients
  • AROM with a painful arc
  • frozen shoulder
  • patients who have been wearing a sling long enough for adaptive shortening of the internal rotators
  • any patient with limited ER or elevation

This is an older video, showing a progression of forces and functional movement based releases for the subscapularis. I also review lateral upper arm release to effectively work on two of the more common upper quarter patterns of dysfunction. You can use the lateral upper arm release on patients who are limited by pain and or post-op protocol, then progress them to the functional subscapularis release once they are no longer limited.

via Pain-Topics.org

A Norwegian study looked at people in chronic pain and how exercise and chronic pain. Since the population was large, they looked at differences between men, women, age groups, and amount of exercise for each. Sometimes when prescribing specific ther ex for stabilization, stretching, or strengthening, I forget to ask them about their general exercise levels.

via Specialist Pain Physio

A good post about current neuroscience and using it to treat pain, not manage it. Education on pain works very well because we now know it's all in the brain.

Via Body in Mind

Body in Mind's site goes over an impressive piece of research that examines whether subgrouping LBP patients affects outcome. Never heard of "searching for the pony," but the snippet at the end is a funny story of its origins.

In my thrust manipulation courses, whether it's con-ed, fellowship, or DPT students, I say there are more indications for thrust manipulation other than to improve pain and ROM.
  • it's awesome
I learned the effects of manipulation from Dr. Stanley Paris:

1) Chemical 2) Neurological 3) Physical 4) Psychological

It's the 4th item that makes it very powerful. Hearing the cavitation or click sometimes works much better than giving any amount of amazing patient education, explanation, or well prescribed exercise. I had a patient today who after 20 minutes of soft tissue work to her cervical spine, upper traps, and first rib mobilizations, said "Is that it?" She still c/o tension in her upper traps and had a loss of cervical extension. Next, I did a sitting upper thoracic thrust, and after hearing the multiple cavitations, she felt much better. That is a huge psychological effect. I have not normally heard "WOW, that deep cervical flexor exercise over the pressure cuff is AMAZING!" Or, "WOW, that cervical retraction with my own generated overpressure, is AMAZING!" I don't mean to take away from the effectiveness of either proven treatment, they just lack that BAM!
  • the patient just knows they need it
Some people are very in tuned to their bodies and what they need. I teach one of the indications for manipulation is a patient just feeling "like it needs to go." Obviously you are still going to evaluate them for ROM, PIVM, repeated motions, etc... but I do often check the area that "feels locked," especially if it is an acute facet lock... just the type that needs a HVLA. In acute conditions, it has been shown in recent research that a lumbar derangement syndrome classification also meets the CPR for lumbar HVLA. I'm sure if it were studied, the same would be true for cervical derangement and HVLA. Both respond to end range, and once motion is restored in the acute condition, function is often restored very quickly. As some patients are unwilling to push past the point of pain with repeated motions, I often manipulate them, improving the pain free range, thus making them more compliant with their HEP.

My only video of my current 54 that has over 10,000 views. You can even hear a volunteer gasping at the end.


I've already tweeted about this via @the_ompt, and it's been all over PT social media, as it should be. This has been shown before in other studies. Hopefully more insurance companies will start reimbursing providers without a prescription for PT. A few in Western New York do, and the public is better off for it. Hard to believe some states still don't have direct access, but this is more ammo for their arguments.

An oldie but goody, one of my favorite questions from NOI. I reference this when my patients ask if their back is feeling better because their knee is now flared up, etc... I normally reply one of my lame standard clinic jokes "I can make that feel better by stepping on your foot." Enjoy the read.

Via Allan Besselink

Will it be too long before consumers actually protest the current health care system? In this era of copays that are more than we currently get reimbursed in Buffalo, NY, I sure hope so.

The lumbar post was written about a month ago. For those of you who read it, you can just skip to the Objective portion below.

previously wrote about how I feel about special tests, so I won't bother including them. Can it be done? Is it like cats and dogs, living together? Mass hysteria?

I started my post graduate training with Stanley Paris and faculty at St. Augustine. After finishing the MTC, I immediately started MDT training and then became CertMDT. It was like having two worlds collide. After some trial and error, plus experience, I formed my own decision making process and successfully combined the best of both approaches. The following is not meant to be comprehensive, but merely suggest go to movements/patterns of dysfunction to assess if you're having trouble. They also can be quickly used if you're following up with a patient who ends up on your schedule when you didn't do the initial evaluation. After all, EACH visit is an evaluation.

Subjective: Mechanism of injury or symptom history. including symptom behavior (location, frequency, intensity, and duration), what activities/positions make the complaints better and worse, functional limitations, and goals. Depending on the type of patient, this should take you 5-15 minutes. This depends of course on how much education you have to present to the patient about their dysfunction. This should also include postural correction for spinal/shoulder conditions for cause and effect. Correct/overcorrect their posture and see if the symptoms change, improve, or centralize. Have them slouch again to see if it returns. Cause and effect is a very powerful teaching tool and should be introduced at the beginning, and not the end. This emphasizes the importance of posture. For follow ups, obviously this is abbreviated.


  • posture/structural
  • AROM
  • PROM, accessory motion testing, springing, overpressure
    • what's the importance of this? - EVERY Joint should have passive motion great than active, it prevents excessive stress to the joint in ADLs

* I don't use repeated motion testing for the cervical spine, but do use MDT for the HEP.

You will often find what I call patterns in dysfunction. The patterns for the cervical spine are:
  • OA in forward bending
  • PIVM restricted in downglide more than upglide, in the upper and lower cervical facets
    • this is because most patients are in flexion, causing the facets to lose backward bending
  • CT junction restrictions
  • T1-3 often restricted in backward bending and/or bilateral rotation
  • 1st rib limitation in inferior glide, most likely on the dysfunctional side
  • myofascial restrictions
    • occiput lateral to medial
    • cervical paraspinals, SCM, scalenes in proximal to distal
    • neural container treatment
      • scalenes
      • pec minor
      • medial upper arm for median, ulnar
      • lateral upper arm for radial
      • anterior radial bony contours for median
      • posterior radial bony contours for radial
      • pronator teres for median
      • you will find after treating the above areas, that neurodynamic treatment/assessment is less painful for the patient, thus making HEP easier to prescribe!
The suggested triad of treatment is 1) STM/TASTM 2) Joint Manipulation 3) Neuromuscular reeducation. Each ST technique should be performed for 3-5 minutes per area and totaling quarters 10-15 minutes. You will find that previously tested PIVM and extremity passive accessory motions may change in their end feels and excursions after STM. If there is still a joint restrictions, use thrust or non-thrust manipulation. 

You should question the use of stabilization for all patients. It is not only difficult for the patient to do correctly, but most are not willing to buy a pressure cuff for an exercise they will not be performing for the rest of their life. If a patient is not progressing, or plateaus with MDT for HEP, only then do I teach them stabilization.

In contrast, it is very easy to teach cervical retractions for HA or cervical pain patients. If they have unilateral complaints, teach them retraction with overpressure into sidebending toward the painful side. After their symptoms are centralized, progress them to cervical retraction with overpressure, and/or extension. This is demonstrated in the video below. I hope the patterns and suggestions help fine tune your cervical evaluation and exercise prescriptions. If you have any questions or comments, contact me below through the contact me button in the blog sidebar.

Via Patrick Ward

I hear clinicians tell their pts about "scar tissue" all the time. What many of them don't differentiate is scar tissue is formed from an injury/inflammation, and adhesions are from immobility. They are two different things, and not necessary occurring with each other, especially without injury. Patrick gives a great explanation of scar tissue, what it is, and what you can do about it.
History: Pt is a 45 yo female that was involved in a MVA 6 months ago. She had onset of right greater than left LE pain to above the knees, facial pain, earache, cervical pain, and bilateral UE pain to above the elbows. Since then, her complaints have been worsening. She had stopped most her regular exercise routine. Her Sx were worse in the morning, at night, with sitting, chewing, cervical and lumbar flexion, and use of her UEs. She was previously very active and was quite upset at how long it was taking her complaints to resolve.



  • flexion: mod loss, PDM
  • extension: sev loss, PDM
  • SB Left mod loss, ERP, right sev loss, PDM
  • rot Left min loss, ERP, right mod loss, PDM
  • flexion: mod loss, PDM
  • extension: sev loss, PDM
Mandible ROM
  • depression 28, PDM, deflects 1 mm to right
  • lateral excursion Left 5 mm Right 8 mm, no clicking noted
Myofascia: severe restrictions in right > left masseter, cervical paraspinals, scalenes, SCM, lumbar paraspinals

PIVM: severe loss of bilateral OA FB, mod loss of C2-4 right > left in downglide, bilateral 1st rib inferior glide, L5-S1 P/A glide

Repeated motions:
  • cervical retraction: decreases cervical pain, better as a result
  • lumbar extension in standing: mod loss, increases lumbar pain and LE pain, worse as a result
Assessment: Signs and Sx consistent with chronic TMD, cervical and lumbar derangements.

Treatment: Day 1, TASTM to cervical paraspinals, STM to masseter, postural correction, use of lumbar roll, HEP of cervical retraction.

Day 2: Pt unchanged, still frustrated. STM to masseter, added 1st rib mobs, subcranial shear distraction which enabled pt to perform cervical retraction with much less pain. Reviewed HEP.

Day 3: Pt reports not being any better. Normally, my deal is some change, ANY change within 4-6 visits or it's back to the referring doc. After some discussion, she stated the frequency of her complaints was less in the cervical spine. We had been focusing on this as per her evaluation, her complaints were upper > lower quarter. I added TMJ mobilizations bilaterally in distraction, lateral glide on right and medial glide on left to improve the slight capsular pattern. She left feeling a bit better about her condition.

Day 4: I added lumbar TASTM and P/A glides to her lower lumbar spine. Afterward, she was able to extend with much less pain, her ROM improved to moderate loss, which continued to improve with reps. Extension in standing was added to her HEP.

On days 5-6: The pt reported no change, and she was getting more frustrated. She stated the TMD specialist recently told her in the best case scenario, she would be wearing her orthotic nightly for the rest of her life. She was "tired of telling everyone she is in pain." She was considering going to a TMD specialist in out of state and a neurosurgeon in another state. 

Here is my David Butler, Explain Pain, moment. 

I told her in my 13 years of practice, even if patients get to be 100%, they ALL wore their orthotic at night. I told her that her condition was the "average" TMD and lumbar condition that I saw daily in my clinic. We needed more time than 3 weeks for 6 months of symptoms. The best specialists in the world could only offer her surgery, which she never wanted, or just another shot and pill regimen. She wasn't interested in that either. 

I then told her that if she gets to be 100%, the orthotic would only be worn when she was sleeping in bed, that she should think "This thing is great! It helps keep my jaw aligned and my symptoms away." It was a small price to pay to get and stay better. She stated that was a good shift in thinking because she was previously very upset she would have to wear it nightly for the rest of her life. When she said she was tired of telling everyone how bad she was doing. I told her, you stated you are feeling better in the face and cervical spine. We have identified a motion for your lower back that helps. From now on, when someone asks, "How are you,"" you tell them, "I'm doing great!"

Something clicked.... she stated she would tell everyone she was doing great from now on. She also felt better about wearing the orthotic and it would be only when she was sleeping anyway. This 10 minutes of discussion probably did more than all my STM, JM, and postural correction combined! It successfully reduced the perceived threat and prevented her catastrophization. I haven't seen her yet for the next visit, but I have no doubt she'll tell me she is doing "GREAT!"

Good read on the effects of training, stretching, and pain and coordination when just one limb is trained or treated. What happens to the other?

Via Body in Mind

Lorimer Moseley discusses clinical results from a group of German Neurologists. Another great read.
Previous update here and original case here

The patient followed up two weeks after his last visit. This was his 7th visit. He stated he was still a bit nervous but was back to all ADLs. He was still slightly shifted, which was most likely his normal structure. ROM was full and pain free in repeated sidegliding, flexion, and extension in standing. Hip ROM was WNL for IR and flexion, which were previously limited. Lumbar myofascia and QL was also WNL to palpation.

I reassured him that the painful memories of this still sub-acute time frame experience will fade, like all pain does. He was also told to keep up with his HEP, albeit less often with the extension in standing, unless he notices a loss. If so, he should just up his repetitions. He understood if his HEP is not taking care of any new acute symptoms to immediately come in for care, as the acute stage is when we can treat it the fastest according to research. This is an important point I make sure to tell all my patients! Another point that I tell all patients on discharge day, "If the Sx return in the absence of trauma, even though I will be happy to treat you again, it is your fault for slacking on your home program."

Via Jeff Cubos

Good post on breathing and relaxing into the stretch. A couple of videos embedded on the post show some insane stretching! 

Yesterday's post on FAI inspired me to share this instruction video on hip long axis distraction. This is a common technique that is in most PTs bag of tricks. I wanted to show a few variations I've picked up over the years plus a thrust manipulation with belt stabilization. Note, I only use belt stabilization for the thrust, not the mobilization.

Indicated for

  • hip capsular pattern - IR > flexion > abduction
  • hip FAI - normally having tender and hard end feel with passive OP in hip flexion
  • treating the neural container of lumbar derangement or radic with LE complaints
  • patients with knee pain - often have hip dysfunction referring to the knee
  • unilateral derangements often having hip dysfunction on the ipsilateral side
  • hypermobile SIJ commonly has ipsilateral restricted hip
I normally perform the mobilization in grade 4 for 3-5 minutes or until it changes. The variations are progressions to increase the stretch or decrease depending on patient tolerance. The thrust I perform twice. Important to note, the cavitation is normally felt by the patient and clinician, but not normally auditory, just like in the video. Enjoy!

Via Craig Liebenson

A good read on a common dysfunction I often see in hip and lumbar patients. Often find with a hard and painful end feel with overpressure in flexion. This is second most restricted after IR in a capsular pattern. Treat it with psoas, iliacus release, functional rectus release, ITB release and hip mobs.
Written by Patrick Ward Via Mike Reinold's Blog

Excellent post by Patrick Ward with references and great explanations that shows why you should consider the TL Fascia for core strengthening, manual therapy, and that ST work should not only be for mechanical reasons. Give it a read!