Q&A Time! Difficulties with Facet Joint Treatment

A reader recently emailed me and ask me how I deal with "facet" joint issues.



He asked: "I wanted to pick your brain about facet joint issues. I am cert MDT and thus I am all about a repeated motion exam. But facet joint issues seem to plague me. I have been taught many ideas but I wanted to see how you diagnose this vs a derangement and what treatment ideas you feel are best for this (Mulligan, MET, soft tissue, MDT, etc). If you get a chance to email me back I would greatly appreciate it. Thank you very much for your time."

Thanks for the question! As a CertMDT, I am surprised you even view it this way as we are taught to look at it as derangement (rapid responder) or dysfunction (slow responder) - because let's just forget about postural syndrome. However, with that being said, I know what you mean, especially in the cervical spine.

How I currently look at spinal problems is

• a loss of loading ability
• difficulty with loading ipsilaterally
• cervical SB
• lumbar SGIS
• thoracic rotation
• bilaterally - loss of extension

Regardless of what is happening pathoanatomically, that's my framework, I always tell patients it does not matter if it's a disc, joint, both, neither, because the solution is often a repeated movement/loading strategy.

How I would characterize a "facet" issue: 

• having an acute loss of motion, often a significant amount
• loading it ipsilaterally to the pain, often produces sharp pain
• motion in unloading either in flexion or sidebending or sidegliding away is usually full, sometimes painful, sometimes not
• there is a deviation upon active motion in loading in the sagittal plane
• i.e. pain on the left
• cervical/lumbar flexion is full
• cervical/lumbar extension is painful and deviates to the right, to avoid loading left while extending

Where MDT often "fails" with these types of conditions is that the patient often needs OMPT/IASTM or other management manually to obtain end range. Getting to end range is the quickest way to reduce these "derangements" or reset them, regardless of what is going on inside both the periphery and centrally. It is very difficult to get a patient hands off to load the area if for hours they can expect pain during movement, no worse, and that's only IF they're getting to end range, because most likely without your help they are not. 

Here is what I find helpful in these cases, MDT must be augmented for your best chances of success

(all examples are pain left)

Cervical Spine

• light IASTM along cervical and upper trap patterns (ipsilateral, contralateral often not needed)
• first rib mobilizations
• thrust manipulation - closing ipsilaterally
• cervical rotation with traction - VERY effective, but can be painful short term
• the progress to cervical retraction with SB OP, as after the above they should much more comfortably be able to obtain end range

Thoracic Spine

• light IASTM to the paraspinals/scapular bony contours, rib bony contours if having rib pain
• thoracic manipulation
• thoracic whip, BAM, you're done in two visits

Lumbar Spine 

• repeated motions often work better, perhaps because the levers are much larger?
• light IASTM to the paraspinals, bony contours of inferior 12th rib and superior posterior iliac crest
• QL and psoas release ipsilaterally (haven't updated my QL release to a nicer version yet)
• lumbar rotation manipulation, loading involved side (watch me get manipulated by a monster)
• after the above, SGIS, REIS with hips offset or just plain REIS or REIL will be much more tolerable, if not pain free

Enabling the patient to obtain end range via OMPT and IASTM is the goal. It's the repetition of the HEP that resets the CNS alarm, raising the threshold for pain. Repetition keeps the threshold high and after a short time (typically a week at most). Then they can resume unloading activities, in a graded fashion.

• for cervical flexion or lumbar flexion, have them perform 5-10 reps, if extension and SB are full and pain free
• then have them repeat the cervical retraction with extension or lumbar extensions prophylactically

Hope this helps with how I look at "facet" issues. Again, I have to stress I don't look at things like facet or disc, only loading issues, and some need a bit more of a manual push than others to get the patient independent.

Keeping it Eclectic...