NAIOMT Level II: C-611 Lumbopelvic Spine II

Faculty: Kathleen Berglund, PT, DSc, FAAOMPT, COMT, OCS, ATC
Clock Hours: Twenty-one (21) contact hours

Audience:

This course is designed for licensed physical therapists (copy of physical therapy license required) who are intermediate learners in the field of orthopedic manual physical therapy.

Pre-requisites:

None, however, in order to receive the maximum benefit from this course, it is recommended that participants have completed C-511prior to taking this class.

Course Description:

This course will utilize case-based instruction to illustrate specific lumbopelvic-hip conditions, and their detailed, specific biomechanical and neurophysiological assessment. Participants will assemble an all-source evidence-informed approach to evaluation and management through consideration of normal, abnormal and applied lumbopelvic and hip anatomy, physiology, biomechanics, and pathology. Coursework will focus on reason-based development of individualized examination sequences aimed at patient/client classification into – management of an initial diagnosis, progression to a specific biomechanical and neurophysiological examination, symptom/intervention/rule-based classification groupings, or referral to another health-care provider. Participants will compare the concepts of health, functioning, pain behaviors and their manifestations, and their role in total patient/client management. Procedural interventions will include education, manual therapy techniques, and individualized neuromuscular rehabilitation prescription, with the goal of restoring normal function and preventing disability. Specific lumbar joint manipulation/mobilization techniques with locking will be a focus of the course.

Teaching methods/learning experiences:

A variety of active learning methods will be incorporated into the case-based presentation of course material, including lecture, laboratory, independent problem assignments, group-based activities, and role-playing.

Overall Course Objectives:

Upon completion of this 21-hour module, the participant should be expected to:

1. Definitively select an initial patho-anatomical diagnosis to an orthopedic manual physical therapy patient/client presenting with lumbopelvic spine or hip pathology.
2. Evaluate and manage the patient/client utilizing reason-based, individualized examination sequences and classify the patient appropriately.
3. Evaluate the “whole” patient, and develop a detailed, individualized prognosis.
4. Formulate an all-source evidence-informed management plan including education, manual therapy, and individually dosed neuromuscular rehabilitation techniques.
5. Demonstrate thrust joint manipulation/mobilization techniques for the lumbar spine and pelvis with focused locking.

Specific Course Objectives

Affective Domain:

Upon completion of this 21-hour module, participants should be expected to:

1. Accept that a strong understanding of the basic sciences of normal, abnormal and applied anatomy, physiology, biomechanics, and pathology are essential to the practice of orthopedic manual physical therapy.
2. Recognize the vital role that all-source evidence-informed clinical reasoning plays in the evaluation and management of orthopedic manual physical therapy patients/clients.
3. Realize that all orthopedic manual physical therapy patients/clients present with certain unique signs and symptoms that require an individualized approach to the evaluation.
4. Accept the concept of patho-anatomical diagnosis as the important goal in the evaluation of the orthopedic manual physical therapy patient/client.
5. Accept the importance of Selective Tissue Tension Testing (STTT) to the evaluation and management of the orthopedic manual physical therapy patient/client.
6. Identify patients who are more appropriately classified using other criteria (Clinical Prediction Rules, Symptom/Intervention based systems).
7. Internalize the importance of prognosis as a central factor in the evaluation and management of orthopedic manual physical therapy patients/clients.
8. Display the judgment required to make decisions that take into account, and are in the best interests of, the overall health and function of the individual.
9. Recognize the importance of all-source evidence-informed practice and balance all sources (clinical experience, literature, and patient preference) in search of best practices.

Cognitive Domain:

Upon completion of this 21 hour module, students should be expected to:

1. Analyze the current understanding of the normal, abnormal and applied anatomy, physiology, and biomechanics of the lumbopelvic spine and hip.
2. Recognize the unique specific biomechanical and neurophysiological examination and differentiate the relative worth of its components as applied to the lumbopelvic spine:
   • Passive Physiological Intervertebral Movements (PPIVM)
   • Passive Accessory Vertebral Movements (PAVM)
   • Tests of Sacroiliac Joint dysfunction
   • Tests of pain provocation (bone, nerve, ligament, soft tissue)
   • Joint stability testing
3. Interpret the biomechanics of the lumbopelvic-hip complex as they relate to the biomechanical and neurophysiological assessment of combined movements.
4. Identify condition (illness) scripts for specific hip presentations:
   • Osteoarthritis
   • Labral tears
   • Avascular necrosis
   • Stress fractures
   • Loose body
   • Biomechanical and neurophysiological dysfunction
   • Contractile tissue lesions
   • Non-Contractile tissue lesions
   • Referred pain to the hip
5. Compare and contrast condition (illness) scripts based on patient age, gender and pain chart information, and definitively select an initial patho-anatomical hypothesis for the lumbopelvic spine from the following:
   • Systemic disease (cardiovascular, pulmonary, neurological, gastro-intestinal, endocrine, vascular, gynecological, musculoskeletal, integumentary, cancers)
   • Fracture/Dislocation
   • Arthritis (degenerative/systemic/traumatic)
   • Spondylolisthesis (congenital/acquired)
   • Disc pathology
   • Radiculopathy
   • Stenosis (central/lateral canal)
   • Segmental dysfunction (hypomobility, hypermobility, instability)
   • Contractile lesions (ligament, tendon, muscle, fascia, interfaces)
6. Question the initial hypothesis through targeted subjective questioning.
7. Interpret red and yellow flag presentations, including central sensitization and neural mobility sensitivity, and discuss the decisions that need to be made about the management of these patients.
8. Review the components of the lumbopelvic spine scan and biomechanical-neurophysiological examination.
9. Recognize the unique ‘Peripheral joint examination’, and differentiate the relative worth of its potential components as applied to hip presentations:
   • Observation
   • Range of motion (functional, active, passive, combined, overpressure)
   • Resisted testing
   • Tests of pain provocation (bone, nerve, ligament, soft tissue)
   • Tests of joint stability
   • Tests of accessory joint motion (joint glides)
   • Palpation
   • Special tests (including tests of motor control and coordination)
10. Identify individual all-source evidence-based tests and measures that are relevant to the diagnosis.
11. Assemble all-source evidence-informed, reasoned, and individualized examination sequences specific to lumbopelvic spine and hip conditions (illness) scripts.
12. Modify individual examination sequences to take into consideration the varying levels of severity and irritability in patient/client presentation.
13. Definitively select a patho-anatomical diagnosis.
14. Formulate an accurate, detailed and individual prognosis for select patient/client presentation including those with poor health, low functioning and illness behaviors.
15. Discuss specific indications and contraindications for orthopedic manual physical therapy intervention.
16. Describe the principles of locking/localization techniques as they relate to specific segmental assessment and management of the lumbopelvic spine and hip.
17. Utilize case examples to formulate specific, all-source evidence-informed, individualized management plans, taking into account the overall health and function of the individual.

Psychomotor Domain

Upon completion of this 21 hour module, students should be expected to:

1. Demonstrate the relevant components of a peripheral joint examination for the hip:
   • Observation
   • Range of motion (functional, active, passive, combined, overpressure)
   • Resisted testing
   • Tests of pain provocation (bone, nerve, ligament, soft tissue)
   • Tests of joint stability
   • Tests of accessory joint motion (joint glides)
   • Palpation
   • Special tests (including tests of motor control and coordination)
2. Demonstrate a specific biomechanical and neurophysiological examination L1-S1.
   • Passive Physiological Intervertebral Movements (PPIVM)
   • Passive Accessory Vertebral Movements (PAVM)
   • Tests of Sacroiliac Joint dysfunction
   • Tests of pain provocation (bone, nerve, ligament, soft tissue)
   • Joint stability testing
3. Demonstrate advanced components of a specific biomechanical-neurophysiological examination (L1-S1).
   • Combined Passive Physiological Intervertebral Movements (PPIVM)
   • Combined Passive Accessory Movements (PAVM)
   • Locking techniques for the lumbopelvic spine.
4. Demonstrate a modified examination sequence to take into consideration the varying levels of severity and irritability in patient/client presentation.
5. Demonstrate the ability to provide education to a patient/client, including prognosis, activity modification, and postural adaptation.
6. Demonstrate orthopedic manual physical therapy intervention techniques:
   • Manualtherapy techniques
     • Localized segmental traction upper-mid-lower lumbopelvic spine with focused locking.
     • Localized segmental distraction/gapping lumbar spine joint thrust manipulation
     • Localized segmental flexion/extension mobilization in the upper, and mid-lower lumbopelvic spine with focused locking.
     • Localized segmental flexion/extension joint thrust manipulation in the upper and mid-lower lumbopelvic spine with focused locking.
     • Longitudinal sacroiliac joint thrust manipulation
     • Localized longitudinal traction to the hip joint.
     • Hip joint mobilization
     • Hip joint thrust manipulation
7. Soft tissue techniques
8. Rehabilitation techniques
   • Neuromuscular rehabilitation of the lumbopelvic spine and hip
   • Strength, mobility, and endurance training
9. Stabilization strategies (including external tape, body mechanics training)
10. Neurodynamic intervention
11. Neural de-sensitizing intervention
12. Demonstrate modified variations of the above interventions to take into consideration the varying levels of patient/client severity, irritability, and patient/client/therapist body type.