One of the criticisms of our profession is that many PTs adhere to the teachings of the "big names." I even started out proudly referring to myself as a Parisite, after graduating from the University of St. Augustine. However you roll, whether it's McKenzie, Mulligan, Paris, Grimsby, Butler, Jones, Rocabado, Maitland, etc.. you are only as good as you the limits you impose on yourself.

It seemed like every spine patient would be easy after starting out with a MDT based curriculum at D'Youville College. After graduating, I immediately started at St. Augustine, and the first thing we heard was some IMO about MDT and how it promotes the evils of hypermobility. After finishing my DPT and getting manual therapy certification, I enrolled in McKenzie's courses. Of course, they present their side of the story about palpation, manual techniques, and 80% of patients not needing therapist manual intervention. Can't we all just get along?

Needless to say, it took some years to really expand my bag of tricks and getting them to work together. Professionally, you should always be a work in progress. Many patients who come back to me after a few years state that I am using very different techniques. I hope the same would be true for you readers. No doubt you are better for following the assessment and treatment techniques of some of the bigger names in the profession. For every 20 patients you help by learning new techniques, you will still find 1-2 you are unable to. Take more continuing education. Think outside the box. Don't limit yourself to dogmatic teaching and especially only the evidence.

If we limited ourselves to EBM, we would all be doing MDT for the lumbar spine, spinal manipulation for cervical and lumbar, thoracic manipulation, but only for cervical spine and headaches, and spinal stabilization. Your shoulder hurts? I'm sorry, there are no quality RCTs that show anything we may do for it will help. But you're in luck, according to the Guide to PT Practice, your frozen shoulder should be better in about 1 year, and it may spontaneously thaw.

My best advice to students and professionals is to finish a series of courses, take time to add the techniques to your repertoire. Experiment, but don't abandon what you found to be useful in the past. Take another series of courses, but not until you're finished with the previous series. You'll find the faculty normally bashes what you just learned from another institute. If you can learn just one great technique that you can use every day, the course will be worth it.

History

As a craniomanibular, oromaxillary, and facial pain specialist, I see a lot of cases that other specialists don't know what to do with. I evaluated a 23 year old pharmacy student who is home for the summer. She has a history of recurrent sinus infections and went to see her ENT a month ago when she developed left ear pain. She also noticed left facial pain and a "bump" in her ear at the anteiror portion of her auditory canal. The ENT prescribed antibiotics which cleared up her sinus issues, but she was left with ear pain and the "bump." By the time I saw her, onset was about 2-3 weeks and it was mostly unchanging.

Evaluation revealed an ectomorphic female, hypermobile, forward head. Symptoms were worse with eating at the "bump" or mass felt in her ear was worse at night. Objectively, she had full cervical ROM. Mandible depression was 32 mm with a deflection to the left, indicating a capsular pattern with left capsule involvement. There was no palpable clicking. Subcranial spine was restricted grade 2 moderate at OA for forward bending. Myofascia was moderately restricted in left masseter, left cervical paraspinals, upper trap, levator scapula. First rib was also restricted grade 2 moderate on the left with inferior glide. She mostly slept on her left.

Treatment

We changed her sleeping to supine or on her right with a pillow supported under left arm. Postural correction and cervical retraction was given to be performed hourly. She was to have a soft food diet for 1 week. Treatment consisted of fascial release/stripping to left upper quarter. Shear distraction as taught by Rocabado was used to gap the subcranial spine. Tool assisted STM was used to release the above mentioned tissues with the exception of the masseter. I don't use the fascialator on the face. It only took one bruise on one out of hundreds of patients for me to discontinue that. At the end of her session, she felt much better and did state it felt better when she wore earbuds to run. The "bump" she felt was either swelling from the bilaminar zone posterior to the mandible condyle or the actual mandible condyle posteriorly from her protracted head. Cervical protraction = mandible retraction. I told her also to wear her earbuds at night. Three visits later with some progression of TASTM and joint mobilization and she is 100%. She only needed to wear her earbuds nightly twice prior to the "bump" going away. Next visit is discharge with a lecture on keeping up with her home program and postural correction FOR LIFE and we have another happy patient and happy referring doctor.

One of the AAOMPT Fellows I trained took a series of courses from a manual therapist who only teaches spinal manipulation. He states that since the likelihood of serious injury or adverse event is so rare, that informed consent and testing like a premanipulative hold is not necessary. Is it really? I say yes, only if you really want your patient to make a truly informed decision on what is best for them. It's equally important for you to CYA as a practitioner as well. How many patients have you seen that said they have been getting regular cervical manipulations for years? Also, they were never aware of there being an approximately 1 in 10 million chance that something like a VBI or death could occur? It's still safe, the odds are definitely in their favor, with other options such as NSAIDs and spinal surgery having serious complications in the 1 for every 10000 range. It is also more likely you will get into a MVA just by driving in your car daily. Even though studies also show there is no way to predict an adverse event (vertebral artery testing, etc), that shouldn't stop you from doing a premanipulative hold. This will test the patient for any warning signs such as dizziness, diploplia, dysarthria, dysphagia, dizziness, nausea, or anything else they would like to report. If any of those are present, I would retest at another visit. The adverse event normally occurs on the second or third manipulation and not the first. Two to three tests and reminding the patient about possible consequences lightly on the second visit should suffice. I document that the patient gave informed consent verbally in my daily SOAP. Informed consent should be a process and not a piece of paper the patient is most likely not going to read. You may talk some patients out of the treatment they may very well benefit from, but you're doing the right thing for both them and yourself.

Laurie Hartman, an osteopath who teaches spinal manipulation states one of the indications for thrust manipulation versus mobilization is that it is a shortcut. If your patient has an acutely locked facet, whether it is cervical, thoracic, or lumbar spine, and it is uncomplicated with no neural signs, they will respond fastest to a thrust manipulation. Your outcomes may be similarly successful with mobilization, but I and Hartman would argue, why bother? You could do it faster and most likely much more comfortable with a thrust manipulation. Even recent research shows that cervical thrust manipulation improves patient's complaints and ROM faster for the first 2-3 visits, even though in the long run, both are good treatment choices. When I present the choice of hammering away at a painful restriction with a grade 3-4 mobilization for minutes at a time versus one quick thrust that may or not even be painful for more than 1 second, many patients choose the thrust. If you were given the choice, and told the research shows both are valid treatment options, which would you choose? The only thing stopping you should be relative skill of the clinician, one of my soft contraindications.

A few of my students from one of the local DPT programs told me they had to learn 26 special tests for the knee. 26!!!!!! It is great to know tests to rule in and out various dysfunction/injuries. I certainly do ligamentous stress testing, and test for instability, if the subjective warrants it. It is ironic however, that special tests are placed LAST in the AAOMPT Fellowship program I teach in. That is if they are to be used at all. I remember being very frustrated at the typical knee patient I used to see as a new grad. Possibly medial and or inferior patellofemoral pain, full strength, full AROM/PROM, ligamentous stress tests and meniscal stress tests were negative. Now what? Ultrafixit? Look for impairments you can treat as a manual therapist, restricted ITB, hip flexors, weak gluteus medius. Screen the hip and ankle for joint dysfunction, which is more likely unless there is an actual knee derangement. Work on those impairments, and your knee patient with all special tests negative, except for perhaps an Ober's test, may just get better.
Another example is cervical compression and distraction. Why on earth would you do a provocation test such  as compression? That just tells you not to do it again, and arguably makes the patient wary of your touch. Distraction? I don't use mechanical traction, so those are another few tests that are useless. Repeated motion exams as taught by McKenzie and Passive Intervertebral Motion Testing both give you a direction for real, skilled treatment. It's also more likely your average uncomplicated cervical patient will get better, and with a lot less visits. The literature supports manual therapy + exercise for spinal conditions. Use your exam to lead you to which areas to use soft tissue and joint manipulation. In the end, if you are using special tests, reassess right after your manual therapy treatment to see if they're negative. Make them useful as a pre and post test measurement. If you decide to drop them off of most exams like I have, your exam will be shorter and more efficient.

There is much debate about the usefulness of Clinical Prediction Rules. Rather than just being another commentary about how great or not the research is, I want to share with you my interpretation of the lumbar CPR for thrust manipulation. Let's forget about the Fear Avoidance Belief Questionnaire, like anyone really administers that. If you take a good history or simply pay attention to your patient tells you, you know how they would score.
Many clinicians think their patient does not fit if they report chronic complaints. If it is an acute exacerbation of a complaint they have had for years, but it is episodic, call it acute! If they have pain below the knee, do something about it! Use MDT (McKenzie), treat the neural container, or anything you find effective to centralize it. If both of the patient's hips have limited IR, mobilize them! Chances are they'll have lumbar stiffness, so that's not normally a problem.

Make them fit the rule. That's how you make the CPR work for you. It doesn't work as well with all patients, or those with true chronic conditions, but it opens up some possibilities for patients and helps to speed their recovery. Sometimes you can make that square peg fit into the round hole.

A colleague once told me my cervical thrust manipulations "felt like nothing." He meant that they were very comfortable. The more components you use to lock the segment you are manipulating, the less excursion you have to put into them. For C2-7, I typically find it easier to start with a downglide or translatory thrust. The components I find most useful are (slight for everything), P/A, SB toward, rot away, translate away, medial shear from L and R hands, slight axial traction. That should provide a good lock. Your hands should be firm but not squeezing. You're not palming a basketball. Use your thrust hand to deliver the manipulation medially and inferiorly and the coupling hand should move medially and superiorly to help. This way you may always use your dominant hand, which helps when learning the skill. It should be AS FAST AS YOU CAN POSSIBLE MOVE, but not forceful. Speed and force are not the same thing. A colleague of mine who is both a PT and a DC says if you get 10/10 cavitations you are using too much force. Good luck and remember informed consent!

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