MSK IV Practical

Neurodynamics
 No pillow during neurodynamic test

 Starting from asymptomatic side
 Observe the range and feel the resistance
 Ask patient about change in symptoms when adding different components
ULTT1 (median nerve)

Therapist position: facing cephalad
Shoulder depression  Shoulder Abd to 90°  Shoulder ER  Forearm Sup  Wrist
and finger Ext  Elbow Ext  Cervical side F
ULTT2a (median nerve)

Therapist position: facing caudal
Shoulder depression  Elbow Ext  Shoulder ER  Forearm Sup  Wrist and finger
Ext  Shoulder Abd to 90°  Cervical side F
ULTT2b (radial nerve)

Therapist position: facing caudal
Shoulder depression  Elbow Ext  Shoulder IR  Forearm Pron  Wrist and
finger F  Shoulder Abd to 90°  Cervical side F
ULTT3 (ulnar nerve)

Therapist position: facing cephalad
Shoulder depression  Wrist and finger Ext  Forearm Pron  Shoulder ER 
Shoulder Abd to 90°  Elbow F  Cervical side F
Slump test (CNS)

Hands behind back
Thoracic F
Cervical F with overpressure
Knee Ext
Ankle DF
Straight leg raise (sciatic nerve)

Hip F and IR with knee Ext
Ankle DF: tibial nerve
Ankle PF and Inv: common peroneal nerve
Hip Add: sciatic nerve
Active neck F: spinal cord
Prone knee bend (L2-L3 nerve roots and femoral nerve)

Pain in anterior thigh: Quadriceps or femoral nerve
Pain in posterior thigh and buttock: L2-L3 nerve roots
Thoracic spine
Observation
- Anterior view
Tip of nose, manubrium, xiphoid process, umbilicus form a straight line
Shoulder level and clavicle level equal
- Lateral view
Earlobe, acromion, iliac crest, back of knee, front of ankle form a straight line
Spinal curvature: Tx kyphosis
ASIS level slightly below PSIS level
No hyper-Ext of knee
- Posterior view
SP of spine form a straight line
Shoulder level, spine and tip of scapula level equal
Waist space equal
Knee crease level equal
Achilles tendon vertical to ground
- Dynamic movement
General spine AROM: hypomobility or hypermobility
Specific Tx AROM (in sitting to isolate Tx): abnormality or asymmetry
- Adam’s test
Patient bends forward with feet together and hands together
Scoliosis is reduced: unlikely deformity, more likely functional problem
Palpation
- Muscle: tenderness, tightness, wasting
Rhomboids, Upper trap, Lat dorsi, Erector spinae, Intercostal muscles
Use dorsum of both hands to feel temperature and sweating of L and R side
- Bone: tenderness
SP: 3 thumb-width below the level of vertebra
TP: palpate out from SP to reach TP of the vertebra 1 level below
Ribs: palpate underneath back muscles
PAIVMs
- Central PA on SP
- Unilateral PA on TP
- Unilateral PA on facet joint
- Costovertebral joint PA on rib angle
Cervical spine
** Must screen VBI before Cx Ax and Rx
Anterior palpation
- Bone: tenderness
C1: between angle of mandible and styloid process of skull
C2: angle of mandible
C3: hyoid bone
C4: upper thyroid cartilage
C5: lower thyroid cartilage
C6: 1st cricoid ring of trachea
C7: above sternal notch
 C2-C4 TP: starting from medial to SCM
 C5-C7 TP: starting from posterior and lateral to SCM
 Avoid pressure on carotid artery, jugular vein, sympathetic trunk
- Muscles: tenderness, tightness, wasting

SCM: palpate manubrium
Scalene: palpate 1st and 2nd ribs
Posterior palpation
- Bone: tenderness
C1 posterior tubercle
C2-C7 SP and TP
- Muscles: tenderness, tightness, wasting

Suboccipitals: palpate occipital condyle
Paraspinal muscles
PAIVMs
- Central PA on SP: Cx facet joints angle upwards 45°
- Unilateral PA on TP
- Upslope
Sensing hand: middle finger over SP and index finger over facet
Moving hand: hold the side of the head
 Rotate head until facet just moves: side F to opposite side to lock the joint
 Perform rotation at the locking position
- Downslope
Sensing hand: middle finger over SP and index finger over facet
Moving hand: hold the side of the head
 Rotate head until facet just moves: side F to opposite side to lock the joint
 Perform side F to opposite side at the locking position
PPIVMS (patient in supine)

- Atlanto-occipital joint: F/Ext and side F
Sensing hand: thumb and index finger over mastoid processes
Moving hand: hold on top of the head
- Atlanto-axial joint: rotation

Sensing hand: thumb and index finger holding C2
Moving hand: hold on top of the head
- C3-C7: side F and rotation

Sensing hand: index finger over facet joint
Moving hand: index finger overlapping the index finger of sensing hand
 Side F: feel the facet moving downwards
 Rotation: feel the facet moving upwards
Transversus abdominis and Multifidus training
Transversus abdominis
- Exercise
Four-point kneeling position: shoulders above hands and hips above knees
 Ask patient to slowly pull the navel towards the spine and hold it
 Start breathing in a normal relaxed manner
 Relax slowly
Trick movement:
 Trunk F and posterior pelvic tilt
- Testing
Place Biofeedback Unit under abdomen with navel in the center
Set pressure to 70 mmHg
 Repeat the exercise
 Reduce pressure by 10 mmHg x 10 seconds x 10 times
Trick movement:
 Reduction in intrathoracic pressure: deep inspiration
 External oblique work: no lower abdomen work, trunk F, posterior pelvic tilt
 Abs work: trunk F, posterior pelvic tilt
Multifidus
- Testing
Prone: back relaxed
 Ask patient to swell out the back muscles under the fingers and hold it
 Start breathing in a normal relaxed manner
 Relax slowly
Trick movement:
 Trunk Ext and anterior pelvic tilt
Combined movement
Cervical spine
- C2-C7
 Rotation and side F is coupled: rotation with ipsi side F
 Ext compresses bilateral facet joints while F distracts bilateral facet joints
 Rotation and side F compress ipsi facet joints and distract contra facet joints
 Neck retraction: upper Cx F and mid-low Cx Ext
 Neck protraction: upper Cx Ext and mid-low Cx F
Thoracic spine
- Mid-low Tx
 Rotation and side F is coupled: rotation with ipsi side F
Lumbar spine
- L1-L5
 Rotation and side F is coupled: rotation with contra side F
 Rotation distracts ipsi facet joints and compresses contra facet joints
 Side F compresses ipsi facet joints and distracts contra facet joints
- Side-lying technique
 Palpate between SP to feel F/Ext position
 Add rotation and side F
Mulligan’s approach
 Pain-free movement
 Frequency: 1 per second
 10 times (+5 times if positive)
NAGs (C2-C7)
Sensing hand: little finger over targeted segment
Moving hand: thenar eminence above the little finger
 Acute inflammatory pain
 Mobilization of stiff joints adjacent to hypermobile segment
 Passive oscillatory mobilization
SNAGs (Cx rotation and side F)

Sensing hand and moving hand: thumb over SP of targeted segment
Ask patient to perform active movement: thumbs maintain pressure
Ask patient to add overpressure at EOR: thumbs perform oscillatory mobilization
 Increase ROM which symptoms are movement-induced
SMWLMs (Cx + shoulder F and Abd)

Sensing hand and moving hand: thumb over SP of targeted segment
Ask patient to perform active movement: observe any Cx rotation and side F
Apply transverse glide and perform oscillatory mobilization at EOR
 Increase ROM of UL which symptoms are Cx-restricted
MWMs (elbow and ankle)

- Elbow
Hands holding lateral humerus and medial forearm
Ask patient to perform active elbow Ext: hands add supination
Perform oscillatory mobilization at EOR
- Ankle
Patient knee in 90° F and calcaneus acts as fulcrum
Hands holding above malleoli
Ask patient to perform active ankle DF: hands add AP pressure
Perform oscillatory mobilization at EOR
 Sustain the pressure until the joint returns to original position
 Increase ROM and reduce pain of movement
Mckenzie’s approach
Lying prone in Ext and Ext in prone
Lying prone in Ext: ask patient to place elbows under shoulders
Stabilize pelvis: prevent pelvic movement
 Prime mover: UL
Ext in prone: fully Ext UL to target lower Lx
 Can fixate belt at PSIS level or targeted Lx segment
 Progression: Ext in prone with overpressure  Ext in standing
Ext in standing
Thumb over SP of targeted segment: thumb add PA pressure
Hand holding iliac crest to stabilize pelvis
Ask patient to bend backward as far as possible
F in supine with knee bent

Ask patient to bring both knees up towards the chest
Ask patient to pull both knees as close as the chest as pain tolerated
 Progression: F in standing  F in supine with overpressure
Self-correction of Scoliosis
Stabilizing hand: forearm supported on wall
Facilitating hand: facilitate pelvis in neutral position
 Shoulder level equal
 Legs front and behind: more stable position
Sacroiliac joint
 1 positive: unlikely SI joint
 2 positive: likely SI joint
 3 positive: highly likely SI joint
Pain provocation test

- Compression test
Patient in side-lying
Apply vertical force to iliac crest
- Distraction test
Patient in supine
Apply vertical force to bilateral ASIS
- Thigh thrust
Patient in supine with hip and knee bent
Stabilizing hand: sacrum
Apply vertical force along shaft of femur
 Generate posterior shearing force through unilateral SI joint
- Sacral thrust
Patient in prone
Apply vertical force to sacrum
 Generate posterior shearing force through bilateral SI joint
Lumbopelvic exercise
- Single leg standing
- Single leg standing with leg movement
- Single leg standing with Bosu
- Impact absorption training: jump up and down
 Hip control and eccentric control

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Neurodynamics

 No pillow during neurodynamic test

ULTT1 (median nerve)

ULTT2a (median nerve)

ULTT2b (radial nerve)

ULTT3 (ulnar nerve)

Slump test (CNS)

Straight leg raise (sciatic nerve)

Prone knee bend (L2-L3 nerve roots and femoral nerve)

- Muscles: tenderness, tightness, wasting

- Muscles: tenderness, tightness, wasting

PPIVMS (patient in supine)

- Atlanto-axial joint: rotation

- C3-C7: side F and rotation

SNAGs (Cx rotation and side F)

SMWLMs (Cx + shoulder F and Abd)

MWMs (elbow and ankle)

F in supine with knee bent

Pain provocation test

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