TPTA Lumbar Course

Course Title:

Using a clinically reasoned, eclectic manual therapy approach in combination with cognitive functional

therapy to treat low back pain.

Brief Resume or Curriculum vitae (CV):

I graduated physical therapy school in 2008 from UTHSC. I then moved to Seattle, WA to pursue post

graduate training with the North American Institute of Orthopedic Manual Therapy while working full time

at an outpatient spine and sports medicine specialty clinic. I became OCS certified in 2011, COMT

certified in 2013, and finished my orthopedic manual therapy fellowship reaching fellowship status with

AAOMPT in 2014. I have been dry needling since 2015. I was introduced to Cognitive Functional Therapy

and Peter O’Sullivan in 2015.

I moved back to my hometown in Memphis, TN in 2014 due to a growing family of 4 kids. I have worked

at Results Physiotherapy and Campbell Clinic. While at these different clinics, I have had the opportunity

to be involved in their strong mentoring programs while being mentored and challenged myself by the

therapists I have had the pleasure to treat along side on a daily basis. I then started my own side

business, 901 Physical Therapy, in September of last year and was able to transition to full time in April. I

have since grown by adding 1 other full time therapist September 1st.

Course Objectives/Clinical Relevance:

1. To understand the importance and usefulness of combining different manual therapy approaches to

treat low back pain.

2. More importantly, to be able to clinically decide when to use different manual approaches for different

lumbar related diagnoses.

3. To be able to perform manual techniques for different clinical scenarios including: lumbar extension

mobilization, Maitland PA mobilization, trigger point release, specific traction, and lumbar flexion

mobilization.

4. To be able to provide 1-2 key movements to give each patient in the clinical scenarios described

above. For example - extension bias, stabilization bias, flexion bias, etc.

5. To be able to apply key aspects of cognitive functional therapy in the treatment of low back pain,

especially when utilizing manual therapy.

TPTA Lumbar Course

I. Intro - what this class is about

A. Clinical reasoning exercise to address different case scenarios of patients with LBP and how to

reason which manual technique (and prescriptive exercises) I have found helpful to use for each

case.

1. All of this with using appropriate language and communication with our patient with a

cognitive functional treatment approach foundation

B. We will go through several of the manual techniques but the most benefit in my humble opinion is

the clinical reasoning.

C. Caveats

1. Very few things I share tonight do I hold with a tight fist but am staying open! Let’s embrace

the gray!

2. Feel to disagree or call bullshit

3. I may cuss a few times

II. Key Principles I use for my clinical reasoning

A. Type of pain

1. Inflammatory pain and acute A-delta pain - there should be a mechanism of injury (one time

incident or pattern of recent overuse)

a) My favorite tests - History, Slump test and standing AROM

2. Somatic (polymodal C fiber) referred pain – maybe no recent MOI

a) My favorite tests - History, Slump test and standing AROM, palpation

3. Hodgepodge of pain (my words!) making it difficult to assign a tissue specific cause - somatic

referred, inflammatory, cognitive influences, fear/stress related pain, diet, sleep influences,

diet – need to wade through it!

B. Pain dominant vs Stiff dominant

1. My favorite tests - History, Slump test, standing AROM

2. Will sometimes categorize these as fear avoidant or confident

a) favorite tests for this - history, standing AROM

C. “Lifespan of the lumbar spine dysfunction” - my own loose organization of LBP digressions that

helps guide my use of the lumbar classification system

1. Sit on our butts in school - maybe starts the dysfunctional process of key muscle/postural

inhibition and early mild degenerative changes, especially if pars injury

2. 20-45 y.o.: Disc injury - pain with bending over, lifting, sitting, stiff in morning

a) Disc injury with nerve root involvement (radiculopathy) or without

3. 30-65 y.o.: “all the mess in the middle” - myofascial pain, trigger points, postural weakness,

“instability”, facet pain, DJD/DDD starting to develop, poor beliefs about back b/c keeps going

TPTA Lumbar Course

out on them - pain with prolonged anything (sit, stand, walk, etc); somatic referred pain and

NOT radicular pain.

a) Telephone pole/guide wire example - i.e. lives at extremes (not in neutral zone)

4. 55-85 y.o.: stenosis - mainly leg pain and minimal LBP (just stiff) - pain in the LEG with

walking that goes away with sitting (DJD/DDD stiffens spine up and “stabilizes” it - so no

LBP).

a) Stenosis causing ischemic leg pain or neuritis (radicular) leg pain

III. Brief Cognitive Functional Therapy intro

A. I first came upon this at an AAOMPT conference in 2015 and listened to Peter O’Sullivan speak.

It significantly influenced me, challenged me, and changed the way I communicate with patients.

B. Brief definition: “CFT is a patient centered approach to management that targets the beliefs,

fears, and associated behaviors (both movement and lifestyle) of each individual with back pain.”

1. Cycle of pain and disability can be fuelled by a nervous systems that is stressed and

sensitized due to negative beliefs, fears, lost hope, anxiety and avoidance, linked to mal-

adaptive (provocative) movement and lifestyle behabiors.

2. Emphasis on listening to the patient’s story using a motivational interviewing approach

3. Listen for “stinkin thinkin” (body schema distortions) and address it

4. Seeks to increase confidence and decrease fear in a patient’s view of themselves and their

pain and their bodies.

5. Seeks to correct these above issues – i.e. correct the maladaptive movement behabiors

C. CFT fits right into the growing movement of pain science study (Lorimer Moseley and David

Butler key researchers)

TPTA Lumbar Course

IV. 33 y.o. male, office worker with acute low back and radiating right leg pain - direct accessA. History

1. Pain with lifting injury – helping his friends move. Localized pain at first but tight as the day

went on. Then woke up in the morning with intense pain. Pain with bending over, pain with

sitting that then travels into right posterior/lateral thigh. Pain with cough/sneeze. Very stiff and

painful first thing in the morning.

2. He saw his MD who gave him muscle relaxers

B. Examination

1. Observation: patient walks with forward bent posture and antalgic/splinted; sits with needing

to constantly shift and can’t lean forward. Sit to stand performed with very erect posture.

2. Lumbar AROM: flexion 40% with 8/10 LBP and leg pain. Ext 50% and stiff w/ central low back

pressure. L SB 50% with right leg pain. R SB 50% with localized LBP.

3. Neuro screen: fatigueable weakness right ankle plantarflexion with MMT (EHL,FHL,Ankle

DF,ever all 5/5)

4. Key Special Tests: Slump test + (doesn’t want to extend knee at all; looking down worsens

pain significantly - i.e. an OBVIOUS positive); SLR + at 30 degrees.

5. Palpation - very tender at L5 with CPA

C. Diagnosis

D. Treatment

E. Cognitive Functional Treatment influence

V. 63 y.o. blue collar worker with acute right anterior/lateral thigh pain – referred by MDA. History

1. 1 week ago after lifting a 20# box into a truck he started walking and had sharp pain right

anterior proximal thigh and could barely walk secondary to pain. He walked bent over. Pain

spread to knee next day. Next morning extremely painful and couldn’t move well or walk. Saw

MD and given steroid dose pack that helped a little but now flared back up again 1 week later

and referred to PT. Patient feels better with sitting but still can’t stand up straight to walk due

to right anterior thigh pain.

B. Examination

1. Observation: sit to stand very antalgic, walks bent over significantly, sits with back straighter

and right leg straight.

2. Lumbar AROM: flexion full no pain, ext lacks 20% to neutral (i.e. bad!!), Bilat SB 50% and

increases his sharp pain in thigh

3. Special tests: Slump negative; can’t lay supine or prone for SLR

4. Neuro screen: Quad reflex 3+, quad MMT 4+/5 on R (5/5 on L)

TPTA Lumbar Course

5. ROM in SL: can’t passively move hip to neutral - stuck at about 10 degrees shy, especially if

bending knee (i.e. + femoral nerve test)

6. Palpation in sidelying: TTP L2,L3,L4 and UPA to L3/4 increases his pain. Too guarded to

discern hypomobility.

C. Diagnosis

D. Treatment

E. Cognitive Functional Treatment Influence

VI. 72 y.o. Male with 9 month history of right antero-lateral thigh pain seen prior by MD - direct accessA. History

1. Saw MD 2 months. X-rays taken showing DJD/DDD throughout; MRI showing disc bulges

and given dose pack with no change and then had L5 injection with no change. Right anterior

thigh pain gradually increasing past 9 months. In the past 4-5 months it is really bothering him

so saw MD with treatment but no change and now can’t stand to walk for more than 10

minutes before it becomes very achy and he must sit down. When he sits he feels fine. If he

rests for 5 minutes it goes away and he can continue. No low back pain.

B. Examination

1. Observation: Walks with normal "old man stiff gait" but nothing out of ordinary and nothing

antalgic

2. Lumbar AROM: Flexion 75% with on pain, extension 30% with no pain at first, L SB 50% no

pain, R SB 50% no pain but bends in flexion quadrant, Holding extension + R SB brings on

his symptoms within 8-10 seconds.

3. Special Tests: neg slump, SLR, femoral nerve test; Negative FABER

4. Neuro screen: negative

5. Hip ROM: bilat hips same with expected stiffness but nothing significant or symptomatic

6. MMT: R quads 4+/5, bilat hip abd and ext 4-/5

7. Palpation: nothing reproduced his symptoms with lumbar PA, Lsp/hip/thigh muscle palpation

C. Diagnosis

D. Treatment

E. Cognitive Functional Treatment Influence

VII. 42 y.o. female cross fit athlete with approx 1 year hx of lower back and right leg pain and “heaviness” - direct accessA. History

1. Long history of LBP as active individual in Cross-fit. Then had increasing right leg pain and

heaviness 1 year ago. MRI – disc bulge. Treatment – injection with great relief. However, in

TPTA Lumbar Course

the past 8-9 months, she’s still had LBP with prolonged walking and activity. She also has

pain with sitting for 2 hours in car, tightness first thing in the morning, and pain/pressure with

lighter squat workout (worked up to 90# but is scared of reinjury) and LBP with box jumps.

a) none of these symptoms last very long once she changes positions.

2. As a side note, she is starting to get hip tightness/pinch with squat.

B. Examination

1. Observation: nothing stands out with gait and sitting/standing posture

2. Lumbar AROM: palms to floor, ext 70% with central LBP, L ext quadrant 50% and sore, R

SB/Ext 80% no pain.

3. Special tests: slump negative, SLR negative, L hip flexion/scour causes “pinch”, L figure 4 =

20 degrees limited (R was WNL)

4. Palpation: + CPA L5 and + UPA L4/5 L and R.

5. MMT: Glut med bilat 4-/5, L hip ER 4+/5, all others 5/5

C. Diagnosis

D. Treatment

E. Cognitive Functional Treatment Influence

VIII. 64 y.o. female with right hip and lateral leg pain - direct accessA. History

1. 4 weeks hx of gradual increasing right postero-lateral hip pain that now extends past knee

down lateral lower leg to foot. Started off with pain when first moving in the morning and at

the end of the day but then has steadily gotten worse. Now it’s keep her up at night and there

is pain with any amount of walking (within first minute of walking). Pain is really strong into the

leg and lower leg.

B. Examination

1. Observation: walks in with limp, avoiding weight bearing on right. Also sits off to the left to

avoid pressure on right hip.

2. Lumbar AROM: flexion 50% with catching into hip and thigh. Extension 80% with some

pulling into hip. L SB full and no pain, R SB 75% and pulling into hip.

3. Special tests: Slump test negative. Single leg stance – her pain and couldn’t hold it.

4. Joint ROM: right hip flexion 80 deg and her pain in butt. Hip ER and IR guarded and painful.

5. MMT: hip abduction MMT immediate pain and can’t hold

6. Palpation: prone lumbar CPA/UPA negative (and whatever else I could think of to stress Lsp

all negative!)

a) Hip Palpation – her pain with glut med/minimus and refers down her lateral entire leg.

C. Diagnosis

D. Treatment

TPTA Lumbar Course

E. Cognitive Functional Treatment Influence

IX. 32 y.o. active male with 5 year history of surgical intervention due to LBP and right posterolateral leg pain — referred by MD who performed recent injectionsA. History

1. Disc injury 5 years ago - surgery within 4 months after failed PT. He did well for a few years,

though still had low level pain. He then had flare ups on two different occasions with return of

symptoms - tried injections w/ some improvement but would still flare up and still daily LBP

and right leg pain. Eventually had Left L3, L4, L5 medial branch nerve ablation. Better but

pain still 6/10 so referred for PT 2 months after this procedure..

2. Aggravants: pain with sitting at work >30’, long car rides (loves to travel with family), pain with

lifting kids, doing yard work; nervous to play golf or try running; p!/fear with picking up around

house

B. Examination

1. Observation: nothing stands out with gait; adapts “extension” posture in L-spine (i.e. standing

from chair, squatting, etc).

2. Lumbar AROM: Flexion 75% with no posterior hip mvt (guarded, no lumbar flexion) with

lumbar pull; ext 60% with 5/10 pain (his spot) right low back, R SB 75% stiff; L SB and bilat

rot all 90% no sx (so really, his movement wasn’t too bad!)

3. Tsp PROM: L and R SB 70%, Rot 80%.

4. Special Tests: SLR negative but tight (R2 60 deg R and 70 deg L); Slump test – 80% knee

extension and negative for inflammation but some tightness increases with chin tuck (neural

tension)

5. Palpation: No pain with PA’s throughout L-sp...except right T12, L1, L2 UPA’s.

a) TTP to the glut med, min, max, piriformis, TFL, psoas, erector spinal (i.e. what’s not

tender??)

6. MMT: hip abd 4-/5 right, 4/5 left; bilat hip flexion and hip ER 4/5, all others 5/5

C. Diagnosis

D. Treatment

E. Cognitive Functional Treatment Influence

TPTA Lumbar Course

References:

1. Clinical and Radiological Anatomy of the Lumbar Spine. 5th Edition. N. Bogduk.

2. Manipulative Thrust Techniques. Erl Pettman

3. Myofascial Pain and Dysfunction: The Trigger Point Manual. Travell and Simons.

4. AAOMPT conference breakout classes and key lectures from Peter O’Sullivan.

5. Continuing Education course manuals and class instructors and fellowship mentors primarily from

NAIOMT. Also from Maitland, Myopain, etc.

6. Amazing clinicians I’ve learned from across the years from Olympic Physical Therapy, Campbell

Clinic, Results Physiotherapy, Rehab Etc, Peak Potential Physiotherapy, etc! (I know this is not a

true reference – but I think it counts!)