Advanced Physical Therapy Manipulation – Objectives

  • Treating specific pathology with specific techniques
  • Dramatically Improve patient outcomes with complex spine cases
  • Increase the safety of manipulation techniques with all pathology
  • New and effective techniques based on biomechanics and pathophysiology

The objective of physical therapy manipulation is to teach physical therapists directional pathology specific spinal manipulation. Physical Therapists are only taught to treat hypomobilityin the spine and this will cause increased pain to many patients when used in real practice on serious pathology. This course will train even the most advanced manipulative practitioners to successfully and safely treat even severe spine pathology. With advanced manipulation it is not when to manipulate the spine but when not to manipulate the spine and how to use manipulation for different pathology. Every spine case is different and responds to different techniques. Many clinical pearls will be shared in this course designed for those who are already doing manipulation in practice. Physical Therapists will learn to quickly identify quick ways to identify specific pathology and treat with many 5 different safe grade 3-5 mobilizations (manipulation techniques HVLAT). This course will explain where the evidence on manipulation and what differences you will find in a clinic based on complex biomechanics and pathophysiology.

Advanced Spinal Manipulation

What you will cover:

Advanced Physical Therapy Manipulation
“Specific techniques for resolving specific pathology”
Directional Specific Movement for Specific Problems

Cervicogenic Headaches:
How to identify: Discuss Differential Diagnosis
Pain stemming from base of neck to occiput or behind the eye
Positive flexion / rotation test

C1 Lateral Translation Manipulation
Pt. prone and contact on C1 Transverse process
Other hand stabilizing and slightly side-bending toward thrusting hand

C2 Cervical Rotation
When pt. rotated to R side then rotate back to left
Contact index finger ½ way between the spinous process and transverse process
Upper Thoracic to decrease tension in attachments of neck muscles

Facet Dysfunction:
How to identify:
Pain with rotation and side bending to the painful side, pain worse with extension
Localized pain and spasms. Less often radicular symptoms
Spurling’s Test often painful to Facet side but doesn’t cause radiculopathy
Very painful and stiff motion testing. Pain often better with flexion.
Treat like a disc first treatment if unsure
How to Treat:
Mid-Cervical Side bending technique to gap opposite side

Rotation with facet gapping on the same side
If severe do above and below or do mobilizations without thrusting. Pre Manipulation mobs and see if helps
How to Identify: Remember facet joints are weight-bearing joints so often when patients are lying down the facet pain will decrease or go away. This is not the case for disc problems. Also, movements that load the facet such as side bending toward the painful side and extension usually increase the pain. Also, flexion and side bending away from a facet problem will often decrease the pain. However, as with most spine pathology when it is moderate to severe all movement will be painful. Also, remember that in the over 50 population there is usually some degree of wear on the synovial linings of the facet joints.
Bent Table Technique:
Supine Cross arm technique with added flexion:
Prone Thoracic Technique:
Mulligan Techniques can often be superior to HVLA when dealing with really acute facet problems. I again strongly recommend you taking his courses.
Cervical Traction:
Rotating, side bending, and flexing exercises away from the pain can be of great benefit. As you become good at manipulation don’t forget your PT biomechanical principle as it often takes combination modalities to help true spine pathology. TMR works great for this population!

Lumbar Facet Pathology:
How to Identify: Weight-bearing joint, pain with standing, can be severe, increased with lumbar lordosis, etc.
Gapping Techniques: Short vs Long Lever Techniques
Adding Leg Kick to short lever techniques (leg kick not advised for disc)
Body contact from sternum to lower thigh for body drop techniques: why would you use a long vs short lever technique? Spread vs focus the forces.

Cervical Disc Pathology:
How to identify:
Pain with spring tests, Spurling’s test, increased pain with flexion, increased pain, and stiffness set off by looking down activity, often radicular symptoms and beware Frank Motor Weakness. Test reflexes/ myotomes.

If bilateral symptoms do not manipulate central disc at the level of the disc
Manipulate 3-4 vertebrae below the disc on the side of worse symptoms
Dreaded Central Disc: take note that central disc is sometimes stenosing the central canal and there is less space for inflammation and bulges. With surgery, they often have to do a laminectomy or discectomy because of the lamina being in way of getting to the posterior disc.
Example: If a disc is a C5/6 with bilateral arm symptoms (central) then do central manipulation above or below the area. Do not manipulate directly into this pathology!
Do pre-manip mobs if have increased pain then don’t do thrust. Try other treatment options.
With all disc pathology, the muscle tension pulls the disc toward the side of pain. Usually, have
Severe paraspinal spasms on the unilateral disc. Do the opposite side first few treatments before manipulating on the painful side. This will be the same for the entire spine.

Thoracic Disc: How to identify.
How to treat. Painful vs Non Painful Side?
Explain and beware the costovertebral joint. Explain biomechanics and what to avoid
Very short and specific HVLAT in prone to close down the disc. Mob then ManipRemember the above and below trick but obey the opposite side rule
Prone vs Supine technique:
why use each
10 Cheater techniques to get cavitation if stiffness
Remember some patients will not cavitate with Grade 5 / HVLAT

Lumbar Disc Pathology
How to identify:
Prone Techniques
Supine Techniques
Sidelying Techniques: Very specific and difficult.
Cheater Techniques:
Things to beware and how to calm down if someone has increased symptoms following disc manipulation. I think this is the number one most underreported negative outcome in medicine. I’ve seen many people who claim to be hurt by manip and its almost always treating the wrong side of a disc. Why did no one show you this before?

Spinal Stenosis: Central vs Foraminal (Discussing Stenosis from Bone narrowing the canal)
Central stenosis when in more advanced stages is difficult for everyone in manual therapy to treat. Regardless of what you mobilize you cannot change the diameter of the central canal. Also with manip, these patients are very difficult to manipulate because of the hypertrophy in the facet joints. It becomes a matter of lack of space. However, in the early phases of central stenosis, you can help alleviate symptoms and improve upright posture with manipulation, soft tissue techniques, and strengthening. Don’t give up and sometimes your results will surprise you. Other treatments I recommend for this population is dry needling to the iliopsoas and use of Brian Mulligan Techniques to increase mobility. If you want to work with advanced spine techniques you need to master Mulligan Techniques. In my opinion, his work and teaching are the best non-thrust techniques to come out of the PT world. Do things to help improve upright posture without exacerbating symptoms.

Foraminal Stenosis: How to identify

Most all gapping and mobilizing to open the canal will be of benefit to these patients.
Forearm Pull Technique seems to offer most relief because you are not putting a direct contact force into the spine. Rather using long levers to open the facets and thus intervertebral foramina.

Sidelying gapping Technique
Most painful side down and you pull pt. legs up to side bend away from stenosis
Note often a patient will feel impingement in the upside hip. If this happens do hip distraction
Sacral Traction in side lying: Grade 3 to Grade 5

Central Canal Stenosis: How to identify
Make as much room as possible around the area.
At the end of the day, you can’t change the diameter of the bone.
Will making the spine more erect increase the diameter of the canal.

Sacroiliac Dysfunction: How to identify and treat.
Posterior Ilium:
Anterior Ilium:
Inflare / Outflare:
Upslip/ Downslip:
Sacral Flexion:
Sacral Extension:
Sacral Torsion:
Pubic Symphysis Dysfunction:
Anterior vs Posterior
Superior vs Inferior

Coccyx Pain: Identify and treat (outside the body)
Coccyx Pulls:
Flexed vs Extended Coccyx:
Left vs Right:
Painful Vs Non-painful side
Discuss Internal Technique:
Associated Risks:

The following methods will be used during the seminar:

1. Powerpoint audiovisual presentation
2. Hands-on Live demonstrations and techniques skills practice.
3. Written manual with text, graphics, and pictures will be given to each learner
4. Access to website review of the above material, including videos of techniques demonstrated.
5. Post Test Knowledge Form – Forms to be handed in and corrected by Instructor.

Advanced Spinal Manipulation Course Agenda

Day 1 – Saturday  
8:00 – 9:00 am Introduction to advanced specific physical therapy manipulation
Hyper/Hypomobility vs. Directional Specificity 
Thinking beyond the evidence and answering the Why?
9:00  – 10:00 am Lumbar Disc : Identify And Treat
10:00 – 10:15 am BREAK
10:15 – 12:00 pm Thoracic and Cervical Disc
12:00 – 1:00 pm  LUNCH
 1:00 – 3:00 pm  Facet Pathology 
 3:00 – 3:15 pm  BREAK
 3:15 – 4:00 pm  Review questions on disc vs facet: Questions and practice techniques
 4:00 – 5:15 pm  Sacroiliac Dysfunction: Identify and Treat
 5:15 – 5:30 pm  BREAK
 5:30 – 7:30 pm  Intro to TMR basic techniques: demonstration and practice 
DAY 2  
7:30 – 9:00 am Lab Review of Day 1
Spinal Stenosis Foraminal vs Central
What can we do? Safe Manipulation for each.
 9:00  – 10:00 am  Coccyx Pain: How to treat from outside/ inside 
 10:00 – 10:15 am  BREAK
 10:15 – 11:00 am  Pubic Tubercle Problems: Identify and Treat 
 11:00 – 12:00 pm  Practice Techniques for each pathology with problem-based learning in Groups of 3
 12:00 – 1:00 pm  LUNCH
 1:00 – 3:00 pm Review Contraindications and Considerations for treatment with complex Cases. Osteoporosis, hemangiomas, fusions, history of fracture, etc.
 3:00 – 3:15 pm BREAK
 3:15 – 5:00 pm Review and answer questions and technique practice and then practice 
 5:15 – 6:00 pm Administer Exam and get course reviews, etc.
Questions & Answers
Forms Filled Evaluation, Testimonial etc..