Incorporating OMPT and MDT into a PT Lumbar Evaluation

I previously wrote about how I feel about special tests, so I won't bother including them. Can it be done? Is it like cats and dogs, living together? Mass hysteria?

I started my post graduate training with Stanley Paris and faculty at St. Augustine. After finishing the MTC, I immediately started MDT training and then became CertMDT. It was like having two worlds collide. After some trial and error, plus experience, I formed my own decision making process and successfully combined the best of both approaches. The following is not meant to be comprehensive, but merely suggest go to movements/patterns of dysfunction to asssess if you're having trouble. They also can be quickly used if you're following up with a patient who ends up on your schedule when you didn't do the initial evaluation. After all, EACH visit is an evaluation.

Subjective: Mechanism of injury or symptom history. including symptom behavior (location, frequency, intensity, and duration), what activities/positions make the complaints better and worse, functional limitations, and goals. Depending on the type of patient, this should take you 5-15 minutes. This depends of course on how much education you have to present to the patient about their dysfunction. This should also include postural correction for spinal/shoulder conditions for cause and effect. Correct/overcorrect their posture and see if the symptoms change, improve, or centralize. Have them slouch again to see if it returns. Cause and effect is a very powerful teaching tool and should be introduced at the beginning, and not the end. This emphasizes the importance of posture. For follow ups, obviously this is abbreviated.

Objective:
- posture/structural
- AROM
- PROM, accessory motion testing, springing, overpressure
     - what's the importance of this? - EVERY Joint should have passive motion great than active, it prevents
       excessive stress to the joint in ADLs
If history warrants and suggests derangement, I perform repeated motion testing. The repeated motions I test are only the ones I think are going to make the patient better. That is from my clinical experience and actively listening to the patient's complaints.

In order of preference, from experience and watching some DipMDTs who I have fellowship trained...

If shifted - correct the shift in standing first and don't bother with assessment further
If unilateral - check sidegliding in standing. More often than not, it will be blocked to the side of the pain (or most distal Sx if peripheral in B LEs)
If bilateral - check extension in standing, make sure to have the patient extend farther and farther. One of the failures is giving up too soon, or not pushing past end range. It often surprises patients who are unwilling to extend due to pain, that repeated motions can improve it!

in NWB
If unilateral - check repeated extension in lying first, then hips offset, the hips offset position I recommend is shown in this video at ~ 3:00 into this video.

Unilateral complaints more often than not have a hip capsular pattern on that side. Look for limits in IR, flex, abduction. Fascial limitations are usually in: ITB of the restricted hip, lateral hamstring/gluteal junctional area
piriformis, psoas, and QL of  the affected side. The lumbar paraspinals are also usually restricted, in a medial to lateral direction and posterior to anterior along the posterior iliac crests, and distal to proximal parallel to the paraspinals.

After performing 1-2 of these releases per treatment (all of them would be too much for most patients). I reassess the repeated motions. I rarely check lumbar PIVM, except in prone springing. More often than not, the spring testing, and especially PIVM in sidelying for approximation and gapping, is unreliable. It is easier and more reliable when using repeated motions to test for an increase in motion, or centralization of complaints. The strict MDT followers would say it makes a patient more reliant on the practitioner if you do manual techniques right away. I say it increases compliance if you make the repeated motion easier for the patient to do at home. I definitely had patients who were unable to perform ANY repeated motion unless manual therapy was performed first. If a restricted hip is found with unilateral (or bilateral) conditions, use OMPT on the restricted tissues and joint. Then use MDT principles for hourly or repeated stretching/loading throughout the day.

Hopefully these suggestions help streamline your treatment, when you look for the "patterns" that experience has taught me!