international academy of orthopedic medicine · 9. enright sj, unnithan vb, heward c, withnall l,...

Postural Function of the Diaphragm in Persons with and without Chronic Low Back Pain

InternatIonal academy of orthopedIc medIcIne

Volume 2, Issue 1

A Contextual and Logical Analysis of the Clinical Doctorate for Health Practitioners: Dilemma, Delusion or Defact?

Orofacial Manual Therapy Improves Cervical Movement Impairment Associated with Headache and Features of Temporomandibular Dysfunction: A Randomized Control Trial

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DIreCtOryJohn Hoops PT, COMT

Managing editor

Valerie Phelps PT, ScD, OCS, FAAOMPT

Chief editor / education Director

Tanya Smith PT, ScD, COMT

Senior editor

John Woolf MS, PT, ATC, COMT

Business Director

Sharon Fitzgerald

executive Assistant

Andrea Cameron

Administrative Assistant/

Marketing Liaison


A Contextual and Logical Analysis of the Clinical

Doctorate for Health Practitioners:

Dilemma, Delusion or Defact?

Orofacial Manual Therapy Improves Cervical Movement Impairment Associated with

Headache and Features of Temporomandibular

Dysfunction: A Randomized Control Trial

The Role of Physical Therapy in

Interventional Spinal Pain Management

ConneCtion The IAOM-US CONNECTION VOLUME 2

Admin Comment: 2013 was a year filled with change and progress for the IAOM-US, and we hope your year was healthy and successful as well. We hope you’ve had a chance to visit our new and improved website (www.iaom-us.com).

We’re very excited to offer two new course formats available in 2014. you can now purchase and complete our stand-alone online modules, which offer you the convenience of completing the course at your own pace from wherever you wish. Or you can have the best of both worlds, and take a hybrid course, which offers one day of online content in addition to two days of traditional hands on course. We’re confident that colleagues will appreciate the added flexibility with these hybrid courses.

As always, the core of our mission is to bring colleagues excellent content, whether it is online, live courses, blogs, or our publications. Our mission with the IAOM-US Connection is to present literature in a clinically relevant manner, which supports the teachings of the IAOM-US. the format of the IAOM-US Connection is a review of current, relevant literature, with specific clinical applications to practice.

We continue to be inspired by the excellent work of our Fellowship program candidates, who constantly add excellent insight to literature and the delivery of manual therapy, as they become clinical experts in the field of orthopedic manual therapy.

the entire IAOM-US team appreciates your continued support and wishes you and yours a very Happy new year!

Cheers!Sharon Fitzgeraldexecutive Assistant


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IAOM-US COnneCtIOn | International Academy of Orthopedic Medicine

Many components of spinal stability have been studied attempting to support different treatment approaches for patients with chronic low back pain. Often a goal in rehabilitation of low back pain is to maintain spinal segments in a biomechanically neutral position during movement. Modulation of intra-abdominal pressure optimizes this bracing mechanism promoting synergistic activity of trunk stabilizers and limb movements. The diaphragm muscle, along with local lumbar stabiliz-ers and the pelvic floor, may play an important role in modulating intra-abdominal pressure, especially during postural tasks.1 Therefore, dysfunction of this muscle could be expected in patients with chronic low back pain.

The aim of this study was to assess dia-phragm excursion and recruitment in a control group and in patients with low back pain. Twenty-nine healthy subjects and eighteen patients with chronic low back pain were recruited. Dynamic MRI and spirometry were tested while patients performed normal tidal (resting) breath-ing and again with isometric limb contrac-tions of the upper and lower extremities.

The results of the study showed no sig-nificant difference in diaphragm position when tested at rest. However, significant reduction of diaphragm excursion was observed while performing both resisted upper and lower extremity contraction in the group of patients with chronic low back pain compared to the control group. Additionally, a more cranial position of the diaphragm during inspira-

tion was noted in the patient group during performance of both resisted upper and lower extremity contraction.

Cranial position of the diaphragm was more evident for the posterior-cranial (crural or lumbar) portion of the diaphragm, demonstrating a steeper angle in relationship to the most ventral-medial position of this muscle, in contrast with the more symmetric recruitment observed in the control group (Figure 1, A and B). It is postulated that this asymmetry could increase anterior shear forces on the ventral region of the spinal column, thus exacer-bating the symptomatology of chronic low back pain.

A high correlation was also noted between total dia-phragmatic excursion and maximum expiratory pressure when lower extremities were engaged, possibly reflect-ing that respiratory muscles other than the diaphragm were more consistently recruited during tidal breath-


Abstracted by Pedro Castex, PT, COMT from Santiago, Chile, IAOM-US Fellowship Candidate & Jean-Michel Brismée, PT, ScD, OCS, FAAOMPT, Fellowship Director

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Kolar P, Sulc J, Kyncl M, Sanda J, Cakrt O, Andel R, Kumagai K, Kobesova A. J Orthop Sports Phys Ther. 2012 Apr;42(4):352-62.

Figure 1: Figure 1. Diaphragm anatomy. According to the result of the study, the more poste-rior cranial portion of the diaphragm (lumbar or crural portion – here in green) presented a more cranial position in respect to the ventral portion in the patient group. A) Illustration, B) Anatomical section.

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ing, whereas the diaphragm was more central to breathing in healthy subjects. Besides that, normal spiro-metric function was noted in both groups, supporting the hypothesis of a compensatory mechanism ac-complished by accessory respiratory muscles.

IAOM COMMENTSOther papers have been writ-ten documenting the relationship between spinal stability and the diaphragm. Hodges et al showed that diaphragm activation would not only increase intra-abdominal pres-sure, but also increased the stiffness of the spine (about 10%).2 Further-more, this same author evaluated the response of the diaphragm to a postural task (shoulder flexion), observing an early activation of this muscle (20 milliseconds) prior to ac-tivation of the deltoid muscle, and having an identical onset of EMG activity with the transversus ab-dominis.3 The study reviewed here complements the current body of evidence supporting the importance of the diaphragm for the control of the spinal movement. Diaphragm activation must be emphasized and incorporated in a reasonable way within the context of a stabilization program. The IAOM has developed the SenMoCOR™ series of courses. This systematic method for move-ment re-education incorporates diaphragm muscle activation as one of the essential strategies when developing the foundational stabi-lization skills (a.k.a. Fundamental 6-pack). Initially, we may elect to use exercises that improve metabolic function of this muscle. Enright et al observed improved diaphragm muscle thickness, increased lung vol-ume and exercise capacity in patients who underwent inspiratory muscle training.4

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Figure 2: Patient lies supine on a comfortable surface. If desired, position the trunk at a 30° inclination, as evidence shows abdominal excur-sion increases in this position.5 A thick pillow under the knees can make this position more comfortable.

Figure 3: Patient places one hand on the upper abdomen and the other hand on the chest. Then, slowly breathes in through the nose and breathes out through the mouth. With inhalation, abdominal breathing is encouraged (movement of abdominal hand), attempt-ing to keep rib cage movement to a minimum. During exhalation, the abdomen should “deflate”. By performing a pursed-lips strategy during exhalation, a retrograde pres-sure in the upper airway is created, thus promoting empty-ing of the lungs, and thereby enhancing the subsequent diaphragm activation.

Figure 4: Once appropriate control of diaphragmatic activation can be achieved, the exercise is progressed by incorporating upper or lower extremity movement along with diaphragm contrac-tion to facilitate a stabilization strategy.

Figure 5: As the patient improves, more complex activities can be incorporated. It might be important to include movements that were ob-served to be deficient in the initial basic functional examination. For example, if the patient demon-strates a deficient movement pattern during squat, the therapist can advise the patient to breathe in using the aforementioned diaphragmatic stimula-tion technique (thus improving spinal stability), then squat down while slowly breathing out with pursed lips, breathe in again and straighten the legs while breathing out with pursed lips. Eventu-ally, an opposite pattern in which patient first breathes out with pursed lips and then breathes in with diaphragmatic stimulation while squatting down and straightening up can be used when the patient demonstrates a more efficient movement pattern acquisition.

SUGGESTED DIAPHRAGM ACTIVATION STRATEGY


References:

1. Hodges PW, Butler JE, McKenzie DK, Gandevia SC. Contraction of the human diaphragm during rapid postural adjustments. J Physiol. 1997; 505 pt 2:539-548

2. Hodges P, Kaigle Holm A, Holm S, Ekström L, Cresswell A, Hansson T, Thorstensson A. Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: in vivo porcine studies. Spine. 2003 Dec 1; 28(23):2594-601.

3. Hodges PW, Butler JE, McKenzie DK, Gandevia SC. Contraction of the human diaphragm during rapid postural adjustments. J Physiol. 1997 Dec 1; 505 ( Pt 2):539-48.

4. Enright SJ, Unnithan VB, Heward C, Withnall L, Davies DH. Effect of high-intensity inspiratory muscle training on lung volumes, diaphragm thickness, and exercise capacity in subjects who are healthy. Phys Ther. 2006 Mar;86(3):345-54.

5. Parreira VF, Coelho EM, Tomich GM, Alvim AMA, Sampaio RF, Britto RR. Avaliação do volume cor-rente e da configuração toraco- abdominal durante o uso de espirômetros de incentivo a volume e a fluxo, em sujeitos saudáveis: influência da posição corporal. Rev Bras Fisioter. 2004; 8: 45-51.

6. Hodges PW, Butler JE, McKenzie DK, Gandevia SC. Contraction of the human diaphragm during rapid postural adjustments. J Physiol. 1997; 505 pt 2:539-548.

7. Hodges P, Kaigle Holm A, Holm S, Ekström L, Cresswell A, Hansson T, Thorstensson A. Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: in vivo porcine studies. Spine. 2003 Dec 1; 28(23):2594-601.

8. Hodges PW, Butler JE, McKenzie DK, Gandevia SC. Contraction of the human diaphragm during rapid postural adjustments. J Physiol. 1997 Dec 1; 505( Pt 2):539-48.

9. Enright SJ, Unnithan VB, Heward C, Withnall L, Davies DH. Effect of high-intensity inspiratory muscle training on lung volumes, diaphragm thickness, and exercise capacity in subjects who are healthy. Phys Ther. 2006 Mar;86(3):345-54.

10. Parreira VF, Coelho EM, Tomich GM, Alvim AMA, Sampaio RF, Britto RR. Avaliação do volume cor-rente e da configuração toraco- abdominal durante o uso de espirômetros de incentivo a volume e a fluxo, em sujeitos saudáveis: influência da posição corporal. Rev Bras Fisioter. 2004; 8: 45-51.

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The terms ‘clinical’ and ‘professional’ doctoral degrees are used synonymously in this commentary. Examples of clinical doctorates include: doctor of medicine (MD), doctor of veterinary medicine (DVM), doctor of dental surgery (DDS), doctor of jurisprudence ( JD); these prac-tice oriented doctorates are typically entry level degrees. Terminology issues are relevant, and the title Doctor is not the domain of any one group of health profession-als. However, it is important that professionals maintain their specialist titles after completing doctoral educa-tion. For example: nurse practitioners should continue to be called nurse practitioners, and so on…. This does not mean that those with a clinical doctorate may not be called “doctor” when holding a professional degree; however, it is important that the nature of the degree be clearly communicated to the public. For instance, physicians, nurse practitioners, and physical therapists should introduce themselves as such rather than identify-ing themselves as “doctor” since the term “doctor” is not synonymous with one professional group.

The move toward a clinical doctoral degree initiated with medical doctors during a transition in the late 1700’s from a bachelor of medicine (MB) to a doctorate in medicine (MD). It took about 17 years for the transition from MB to MD. More recently there has been a surge of clinical doctorates in various allied health fields, in-cluding doctor of clinical nutrition (DCN), occupational therapy (OTD), nursing (DNP) and physical therapy (DPT). The clinical doctoral degree is based on knowl-

edge and skill needed to deliver advanced care within the scope of the specific practice. Clinical doctorates ought not to be confused with post-professional doctor-ates as they are not intended to emphasize research or teaching. Post-professional doctorates include doctor of philosophy (PhD), doctor of education (EdD) and doc-tor of science (ScD). The PhD, EdD and ScD degrees are commonly awarded to indicate mastery of an academic subject. The United States Department of Education and the National Science Foundation consider the aca-demic research degrees of PhD and ScD to be equivalent as well as the most prestigious academic degrees, due to their emphasis on development and application of new and advanced knowledge. Dilemmas in regard to a clinical doctorate can include: confusion of the difference of clinical doctorate from research doctorate or master’s degree and expectation of effectiveness of care delivered. One misconception of the entry-level clinical doctorate is that it not only prepares one for clinical practice but also for academics and re-search. The entry-level clinical doctorate is not designed to prepare the professional for academic teaching or re-search. The entry-level clinical doctorate is here to stay; the American Physical Therapy Association is pursuing autonomous and professional development through the advancement to the level of DPT.

With the push for a profession to have only entry-level doctoral degrees, the classic conundrum of economic

A Contextual and Logical Analysis of the Clinical Doctorate for Health Practitioners: Dilemma, Delusion or Defact?

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Royeen C, Lavin MA. J. Allied Health. 2007; 36:101-106. Abstracted by Tanya Smith PT, ScD, COMT, IAOM-US Fellowship Candidate

“The purpose of this commentary is to address some of the common misunderstandings of the clinical doctorate, place the doctorate in context of larger educational change and innovation,

and share summary judgments about the nature and course of the newer doctoral degrees.”


supply and demand must be addressed. The impetus for all institutions to offer only clinical doctoral programs may have less than optimal consequences; if the school is not a top tier school that provides post-professional doc-toral education and research in many other disciplines, this could lead to subpar program development during the transition from masters to doctoral degree. Granted, there is a societal need for a higher level of education for health care professionals given the change in popula-tion demographics to an older aged group with multiple health conditions that are often considered chronic. The author predicts that in less than one generation the majority of health care providers in allied health will be educated at the clinical doctoral level at a minimum. IAOM COMMENTS:There is no doubt that population demographics are changing and expanding in regards to the patients who are in need of physical therapy services. The movement toward higher education and profession-alism is certainly warranted with complex pain and musculoskeletal disorders. Proponents of the DPT contend that the professional doctorate will speed up development and acceptance of autonomous practice. Autonomous practice is one place physical therapy falls short in the definition of a profession. Although many states allow direct access to physical therapy care, some insurance payers do not routinely reimburse for physical therapy care without a physician referral. Some even suggest the DPT is a mechanism to buy the respect of the public, insurance payers and health care colleagues. The profession of physical therapy contin-ues to develop and expand breadth of knowledge, irre-spective of critics. The emphasis on DPT education is to improve critical thinking skills, as well as conceptual, integrative competence. The problem lies in the fact that critical thinking skills are a higher order learning process. Do we expect an entry-level professional to employ higher order thinking skills? I think the answer is no; after all, it is an entry-level degree that gives a good foundation for professional career development. The DPT with its frequent employment of the term ‘doctor’ has led to confusion of the public. As stated in the above commentary, it would be advantageous for us to present ourselves clearly by our professional distinction rather than our academic degree. We are all physical therapists whether we hold a PT BA, PT BS, MPT, MSPT, DPT, PT ScD, or PT PhD. There should be no confusion among the public we serve or the team of professional colleagues with which we coordi-nate the care of our clients. All colleagues with doc-

toral degrees have the distinction and right to be called “doctor” but who does this serve?

The Latin term for doctor literally means teacher, Doe-co translates to “I teach”. The doctorate appeared first in medieval Europe as a license to teach. The history of the terminal academic degree is mastery of subject in order to teach. Whereas the professional/entry-level doctorate was developed to improve the training of professionals by raising the requirements for entry and completion of the degree in order to enter the profes-sion, the trend of professional doctorates is driven by professional associations and leads to criticisms that the programs lack rigor in the new doctoral programs.

The impetus to write about this topic came after a colleague in orthopedic surgical medicine voiced his concerns to me following multiple incidents with DPT’s contradicting post-surgical advice that was given by the surgeon. The therapists in question commonly referred to themselves as doctor in the clinical setting, which potentially led to confusion for the patients. The patients stated to the surgeon, “I do not know which doctor to listen to”. Subsequently, this surgeon stopped referring to those physical therapists. It is the humble opinion of this author that such events do harm to the profession of physical therapy and although this instance may be isolated, I am aware of similar circumstances in multiple practices across the country. I think it is time that the physical therapy professional programs educate students about the his-tory, evolution and diversity of doctoral education and most importantly include lessons in humility.

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References:

1. Plack M. The Evolution of the Doctorate of Physical Therapy: Moving beyond the contro-versy. J Phys Ther. 2001.

2. Rothstein JM. Education at the crossroads: Which paths for the DPT? (editorial). Phys Ther. 1998; 78:454-457.

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Orofacial Manual Therapy Improves Cervical Movement Impairment Associated with Headache and Features of Temporomandibular Dysfunction: A Randomized Control Trial

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Von Piekartz, H et al. Manual Therapy. 2013; 1-6. Abstracted by: Denise Schneider, MPT, FAAOMPT, COMT, ATC, Lombard, Illinois.

Individuals who suffer from temporomandibular joint dysfunction (TMD) typically complain of jaw pain and limited jaw movement; however, headache, neck pain, and neck stiffness are commonly reported as well. Head-ache occurs in 24% of people diagnosed with TMD.6 TMD includes the temporomandibular joint (TMJ) and associated musculature and may result in limited and painful mouth opening, muscle spasm, and/or trigger points. This may then contribute to cervical impair-ments and headache. The purpose of this study was to determine whether manual therapy directed at orofacial structures in addition to manual therapy directed at the cervical spine, was more effective in treating cervical impairments in subjects with cervicogenic headache and TMD as opposed to manual therapy of the cervical spine alone.

Forty-three subjects with a diagnosis of cervicogenic headache were included in this study. They were required to have features of cervicogenic headache such as: pain referred from the neck to the head; limitation of neck movement; headache pain upon palpation of the upper cervical spine; and symptoms of less than 3 months dura-tion. The subjects were also required to have at least one of four signs of TMD including: joint sounds; deviation during mouth opening greater than 2mm; passive mouth opening less than 53mm; and pain during passive mouth opening greater than 32mm on VAS. Although subjects may have had physical therapy treatment directed at the

cervical spine, they were excluded if they had physical therapy treatment for TMD.

The subjects were randomly assigned to one of two groups. Twenty-one were assigned to the “usual care” group which received cervical spine manual therapy; twenty-two were assigned to the “orofacial care” group which received orofacial manual therapy plus cervical spine manual therapy.

Three tests were used to measure cervical spine impair-ment. First, cervical range of motion in all directions was assessed using a digital inclinometer. Second, the flexion-rotation test as described by Hall et al3 was performed to assess mobility at C1-2. Lastly, joint hypomobility and pain were assessed with central and unilateral posterior-anterior accessory movements of the upper three cervical vertebrae. These tests were performed at three different intervals including baseline, after six treatments, and at six months.

The treatment rendered was based on the specific clinical exam and consisted of six, 30 minute sessions within a three to six week time frame. The orofacial care group re-ceived manual therapy treatment to address masticatory trigger points, muscle tightness, and temporomandibular joint restrictions. This group also received manual thera-py treatment directed at the cervical spine. The usual care group received only cervical manual therapy.


The results indicate significant improvements in the oro-facial group versus the usual care group with all measure-ments. The orofacial care group demonstrated a signifi-cant increase in cervical range of motion at the three month mark. Pain and hypomobility improved at the three month and at the six month mark. Likewise, the orofacial care group improved markedly with the flexion-rotation test at the three month and the six month mark. The article concluded that subjects with features of cervi-cogenic headache and signs of TMD benefit from a treat-ment approach that utilizes both cervical spine manual therapy and orofacial manual therapy to improve cervical impairments. Clinicians should be aware of TMD signs and incorporate TMD treatment as appropriate with the cervicogenic headache population.

IAOM-US COMMENTS:Dysfunction of the TMJ and/or associated muscula-ture may contribute to cervical impairment in patients who suffer from cervicogenic headache. Literature advocates that treatment of TMD may result in signifi-cant decreases in headache complaints. Pain and/or decreased mobility of the TMJ, and soft tissue restric-tions in the masticatory muscles may contribute to cervical spine impairment. Therefore, it is necessary to address these deficits with this patient population. TMJ mobilizations are indicated for pain, decreased joint mobility, and decreased range of motion. Traction is utilized for pain relief (Figure 1).

Grades 3 and 4 joint mobilizations are indicated when there is a limit in joint mobility and range of motion. For example, to restore mouth opening, the position of the patient and the PT are similar to that described in Figure 1. However, in this instance a caudal ventral glide is performed. This may be performed as oscil-lations or sustained holds, at 40 seconds for 4 repeti-tions.

Soft tissue restrictions of the masticatory muscles, such as muscle spasm or trigger points may contribute to cervical impairment and headache. For example, restrictions of the temporalis and masseter may lead to pain and/or a limit in jaw range of motion. Physical therapy interventions include transverse friction mas-sage and myofascial stretching. Treatment to decrease soft tissue restrictions in these muscles have been shown to increase mouth opening by 2.5 to 4mm.5 Transverse friction massage is performed in order to promote tissue healing, provide an analgesic effect, and increase range of motion. Pressure is applied in one direction and performed for approximately 3-5 minutes. Transverse friction applied to the masseter is performed with the patient in a supine position (Figure 2).

Transverse friction of the masseter is followed by myo-fascial stretching (Figure 3.) The stretch is held for 30 seconds and repeated three times.

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Figure 1: TMJ distraction. The patient is positioned in supine. The therapist stands on the side opposite to be treated. The therapist uses the caudal hand to perform the mobilization and the cranial hand to stabilize and to palpate the joint. The caudal thumb is placed on the molars, while the index and middle fingers grip the inferior angle of the mandible. The patient is instructed to relax his/her jaw so that the teeth are resting on the therapist’s thumb. Grade one or two distraction is performed in a caudal direction for 40 seconds at 4 repetitions.

Figure 2: Transverse friction massage of masseter. The patient is positioned in supine. The therapist’s thumb is placed inside the mouth at the zygomatic arch, the index and middle fingers are placed op-posite on the outside of the patient’s cheek. The therapist finds the most tender area and utilizes a pincer grip to perform the technique. The therapist works down towards the angle of the mandible.

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IAOM-US | COnneCtIOn 9

Transverse friction massage to the temporalis is also performed for pain relief and improvement of jaw opening (Figure 4). The same principles are applied as the pressure is applied in one direction, in the areas of tenderness, for approximately 3-5 minutes.

Myofascial stretching of the temporalis is performed after the transverse friction massage. The technique utilized is the same technique used to stretch the mas-seter (Figure 3). TMD is commonly associated with symptoms affecting the head and neck such as headache and cervical spine disorders. Manual therapy is not only used to decrease pain and increase jaw range of motion, but is also directed towards alleviating associated impairments of the cervical spine.5 Therefore, in order to provide comprehensive treatment to patients with features of cervicogenic headache and cervical spine impairment, interventions directed towards TMD must be consid-ered as well.

References and Suggested Reading:

1. Buescher, Jennifer. Temporomandibular Joint Disorders. Am Fam Physician. 2007; 76:1477-84.

2. Furto, E et al. Manual Physical Therapy inter-ventions and exercise for patients with temporo-mandibular disorders. J of Craniomandibular Practice. 2006; 24(4):283-291.

3. Hall, T et al. Interrater reliability and diagnos-tic validity of the cervical flexion-rotation test. J Manipulative Physiol Ther. May 2008; 31 (4): 293-300. Kostopoulos D, Konstantine R. The manual of trigger point and myofascial therapy. New Jersey: SLACK Incorporated; 2001.

4. McNeely, M. et al. A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Phys Ther. 2006; 86:710-725.

5. Oliveira-Campelo, N et al. The Immediate Effects of Atlanto-occipital Joint Manipulation and Suboccipital Muscle Inhibition Technique on Active Mouth Opening and Pressure Pain Sensitiv-ity Over Latent Myofascial Trigger Points in the Masticatory Muscles. JOSPT. May 2010; 40 (5): 310-317.

6. Ozkan, F et al. The relationship of temporoman-dibular disorders with headaches: a retrospective analysis. Agri. January 2011; 23(1):13-17. 7. The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004; 24 Suppl1:9-160.

8. Winkel D. Differential Diagnosis of the Spine: Nonoperative Orthopaedic Medicine and Manual Therapy. PRO-ED, Inc; 1996.

Figure 3: Myofascial stretch of masseter and of temporalis: The patient is positioned in supine. The therapist sits on the side to be treated. The therapist places the cranial hand on the patient’s forehead while the caudal hand is placed on the patient’s chin. The therapist performs neck extension with the cranial hand while simultaneously performing jaw opening with the caudal hand.

Figure 4: Transverse friction of temporalis: The patient is positioned in supine while the therapist is positioned at the head of the table. The therapist uses the caudal index and middle fingers to perform the technique while the cranial hand stabilizes the fore-head. The therapist begins by pal-pating superior to the zygomatic arch and works along the muscle to find the most tender areas.

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Join esteban azevedo, pt, scd, comt and amy hay-azevedo, pt, scd, comt for this exciting andinformative pain course for a comprehensive approach to spinal pain management! Esteban and Amy have worked alongside interventional pain physicians for 13 years and want to share their experience of utilizing IAOM-US evalu-ation and treatment fundamentals with interventional pain management procedures for the treatment of recurrent and chronic spinal pain.

Come learn how to quickly determine spinal paingenerators based on patient profiles. Develop comprehensive physical therapy treatment plans based on the pain generators and systems of dysfunctions. Understand techniques performed by interventional pain management physicians and the considerations for physical therapy when working together.

The Role of Physical TheRaPy in inTeRvenTional sPinal Pain ManageMenT is an innovative course for physical therapists, physicians,

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This course includes a CD full of patient education handouts, cervical, thoracic, lumbar and SIJ exercise programs, a plan of care form, diagnosis explanation form, 6 state pain program, and pain management algorithms. PDFs of all the course slides are also included on the CD.

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