Several years ago, a doc referred a very nice older gentleman over for some help. He had chronic LBP that was central, and had no radiation. He had had a congenital deformity of his right foot and wore custom shoes to compensate for the leg length discrepancy it made. It was also very stiff in dorsiflexion with -10 degrees of dorsiflexion. He was in between custom shoes, and his PCP sent him over for some "temporary" relief until he received his shoe. For some reason, there was a delay and he would not get it for four weeks.

History: He presented with 8/10 complaints of severe LBP. Duration was approximately 3-4 months, but worsened since not having his custom shoe in the past two weeks. Sx were worse in sitting, with bending, and in the morning. Sx were better with standing, and as the day progressed.

Objective: Fair sitting posture. His right hip had a hard end feel in IR and was limited to about 15 degrees. Lumbar flexion in standing was moderately limited and had pain during movement. Repeated flexion was painful, increased his complaints, and worsened as a result. Lumbar extension in standing was severely blocked, had pain during movement, decreased complaints, but was no better as a result. (Freshen up on your MDT Terminology if the increase/decrease, better/worse is throwing you for a loop!) When repeated flexion in standing makes Sx worse, I don't bother with repeated flexion in lying. Seems redundant to me. I felt like he could get more extension in lying; in prone he was severely blocked at first. After several repetitions, his extension improved, but only to moderate loss. His LBP decreased, and was better as a result. He had a severe loss of hip extension bilaterally with hard end feels, which did not change with 2-3 sets of repeated extension in lying. Lumbar spine had moderate restrictions in fascial mobility in a distal to proximal direction, plus medial to lateral along the bony contours of the posterior iliac crest.

Assessment: Signs and Sx were consistent with a chronic lumbar posterior derangement with accompanying hip dysfunction.

Discussion: The derangement gave good prognosis because he could rapidly not only his Sx intensity, but also his range of motion. Anything that changes quickly falls into the derangement category because it doesn't have to be remodelled. I don't use the MDT method for dysfunction because as a manual therapist, we can do better than just having the patient go home and stretch it on their own. In this day and age of up to $50 copays, I'm not going to tell a patient they have to do it all themselves, especially if I can do some manual work to speed up the process. Hips fell into the dysfunction category, which required manual therapy for the tissue remodelling process.

Plan: The patient was to do repeated extension in lying, 10 times/hourly, use a lumbar roll in sitting, and avoid forward bending as much as possible. STM was applied to the paraspinals on the first visit along with hip long axis distractions. This improved hip extension but not significantly, indicating the dysfunction. The pt did note that repeated extension in lying was more comfortable for him with less pain during motion after the manual therapy.

Follow up 2: He was originally seen for a 7 am evaluation, and he was one of the most compliant patients ever!  He estimated doing at least 150 pressups that day and stated that his chest and arms were REALLY SORE! He was very pleased though. He told me his lower back was at least 75% improved in pain intensity and duration. Flexion was still painful, but extension was greatly improved. I added hip mobilizations with a belt and mobilization with movement (Mulligan) for his limited right hip. Psoas release was performed to increased bilateral hip extension. STM was again performed to his lumbar paraspinals. His repeated extension in lying was greatly improved to only moderate to minimal loss.

Follow up 3: Almost 100% better. Hips still limited in extension, but now with a more firm end feel, right hip IR improved to about 20 degrees with a hard end feel. Kept up with the same tissue techniques. Repeated hip IR was instructed for HEP



Despite the pt being 100% pain free by visit 4, I still treated him for 3 more visits to clear up his remaining hip dysfunction. He was very pleased and his PCP became one of my top referring docs as a result! Mr. Compliant still comes to me once a year for a little soft tissue work and a quick manip to his right talocrural joint to help with his ankle stiffness and pain for 1 visit, but hasn't had LBP in years as a result. He still performs press-ups 10 times/hour after 10 years!

Mervyn Waldman - Mechanisms in osteopathic medicine (part 1) - Sacral Musings - Osteopathy Community:

'via Blog this'

via InTouch Physical Therapy Blog

'via Blog this'

Via LearnersTV. Interesting to watch over again after you've been out of the classroom for a while.

In Touch Physical Therapy Blog:

'via Blog this'

I don't normally administer this questionnaire as I prefer to get a feel for my patients by speaking with them during the eval and follow ups. I can surmise who is going to respond and who is not going to respond to manual therapy and/or stabilization/ther ex. Still, it is a good explanation on it and various sources are provided for evidence.

I want to share a technique that is as useful as it is uncomfortable. The psoas has spinal attachments, and is more than just a hip flexor. Some studies think it functions as a stabilizer. Since it attaches to the spine, the only way to release it manually is to go DEEP.

Another great article by the NOI Group. Do I think TrA strengthening is important? Yes! Do I prescribe it for everyone just because some research shows it helps? Absolutely not! If I can get someone better with manual therapy and postural correction plus some MDT, I won't bother giving them core strengthening (or deep cervical flexor strengthening) unless they plateau with the easier HEP I'm already prescribing.

I hope you have found the skull crusher or subcranial shear distraction as useful a technique as I have. Whether you are a MDT, Paris, Mulligan, or overall eclectic practitioner, ANYONE who treats cervical patients should consider using it. Below is a video of variations on unilateral progression and functional movements to increase the stretch as progressions. Check it out!

Via Chaitow's Chat. Some research that points out why thrust manipulation works to improve ROM and decrease pain. Also describes why other less aggressive tx like mobilization, MET, etc also may work. Hint.. it all points to fascia!

A former patient called me a while back to make an appointment for her elbow. She had to cancel the appointment because her doctor suggested she go somewhere else. One PT had her wearing a splint and resting (for SIX MONTHS). He just started some strengthening exercises. Another told her to perform repeated end range loading into elbow extension. The explanation wasn't given why, and the patient didn't believe the exercise to be appropriate, despite it being indicated for her condition. She even consulted a hand/wrist surgeon who basically told her to come back when she wanted an injection.

Six months ago, the patient lifted very heavy groceries and carried them with both elbows extended. Her right elbow around the epicondyle became painful and since then has developed into paraesthesia radiating into her hand in the first two digits posteriorly. Symptoms are worse with any use of her right arm and better with rest.

Objectively, I found moderate restrictions along her anterior radial bony contours, lateral right upper arm junctional area between her biceps, triceps, and anterior deltoid and biceps, and minimally along her common extensors, which she had been stretching for months. She had full ROM in all planes for forearm and wrist, and elbow flexion. Elbow extension was limited at least 5 degrees with a springy and painful end range, indicating capsular infold or derangement. Upper limb neurodynamic test was limited with radial nerve bias. Resisted wrist extension and grasping were painful. Mulligan humeroradial lateral glide was negative for abolishing pain with functional testing. Since she had history of TOS like complaints, I also found right 1st rib dysfunction, restrictions in right cervical paraspinals, and scalenes.

Treatment: TASTM to anterior radial bony contours and lateral right upper arm junctional area. Thrust manipulation (Mill's) to right elbow to improve springy end feel. Neurodynamic tensioners to radial nerve were actually near WNL for ROM and did not reproduce pain after the TASTM and manipulation. This was given for a HEP along with repeated end range loading to reduce her elbow derangement into extension.

Discussion: Her lack of elbow extension, which the patient reports having for years, most likely caused some irritation from the end range loading. After months inflammatory soup around the area, the radial nerve became entrapped and is now causing some paraesthesia. Some simple treatment to the neural container along with restoration of her elbow extension should do the trick.

I only saw her one visit so far, but progressed more with her in one visit than she had in six months. She was very thankful and even emailed me she was feeling much better a few days ago. Her second and third follow ups are this week and I have no doubt she will be a six to eight visit case at the most. I will most likely continue with the first set of treatments and start with her cervical spine and 1st rib work. Will update this post when her treatment is complete if all goes well!

UPDATE 8-23-11
The patient returned for her first follow up after evaluation and was very pleased. She stated she was 90% better after the first visit. She also stated it wasn't 6 months she was seeing other practitioners, it was 7-9 months! Her right elbow extension now had -10 (hyperextension) with a bony end feel. Radial nerve was still minimally restricted with neurodynamic testing. She had some ecchymosis on her right lateral upper arm junctional area, but that area and anterior radial bony contours both improved for fascial mobility. I would estimate 2-3 more visits for a bit more tissue work, progression on eccentric loading, then a graded return to function on her own.

Credit for this technique goes to Dr. Mariano Rocabado, from Santiago, Chile. I think it's quite unfortunate that he is known for his so called "6x6" home exercise program for patients with TMD. Many students and clinicians think that is the only thing he does, much like they think McKenzie only does extensions.

Rocabado's caseload is primarily TMD, but he is a manual therapist first and foremost. One of the best I've ever trained with. He noticed that some patients were not responding to the typical OA gapping techniques and the HEP of deep cervical flexor retraining and postural correction nodding exercises did not relieve their HA and/or cervical pain. Upon saggital x-ray view, these patients had an atlus that was adhered to the occiput both in neutral and in flexion, with the gapping occurring at AA instead of OA. This decreases subcranial space, is palpably less and tender to touch. This in turn leads to bony and soft tissue entrapment of greater occipital nerve causing radiating HA into the frontal and temporal region. Radiating complaints may also refer to the upper traps.

He devised a technique that involves A LOT of A/P shear through the frontal cranium. Mobilization hand is on  the occiput, stabilization hand grasps C2, and not C1. The shear stretches the rectus capitus posterior minor, which is thought to be adhered and limiting the OA nod. Mobilizing UE shoulder's softest anterior part goes on the patient's forward. You stand to the side opposite your mobilizing arm.

The shear I estimate is at least 30-40# and is done by dropping your weight onto their forehead. I do this first to make sure the patient is ok with it. The distraction is performed by pulling on the occiput very hard to gap OA and roll up into cranial forward bending. Stabilization is on posterior C2. When the distraction is performed, you INCREASE the shear to prevent cervical forward bending, and isolate cranial forward bending. This is a pressure on/pressure off type mobilization and would be a lot to do as a sustained hold or grade 4. 2-3 sets of 6 reps are performed. It is normal for the patient to have difficulty breathing at end range.

This not only improves OA forward bending, but can relieve HA, and cervical pain. Rocabado even has x-ray proof after using this technique of before and after a few weeks of this plus postural correction, cervical retraction and deep cervical flexor exercises. The patients have increased subcranial space and gapping at OA in flexion. That's some EBM for you!

Btw, a patient of mine several years ago nicknamed this technique the skull-crusher, and it's stuck ever since (but I don't document it that)

Via Mike Reinold's blog! Great progression for two very necessary exercises for most if not all lower quarter dysfunctions!

I was recently given some advice from a colleague to change "The Fascialator" to a more professional sounding name. Now, I always tell people who purchase a tool for their use what I called it, but they could call it whatever they want. I have a few ideas in my head, but if you readers out there have any, submit them! After a week, winner gets a free TASTM Tool!

One of the things that makes us better as a health care profession is our emphasis on home exercises. One of the things I always make clear to all patients is, we can help you, but you're responsible for yourself the entire time you're not in our clinic. Compliance is NOT an option, neither is posture, or for most people, deviation from the prescribed HEP frequency/intensity/duration.

As a CertMDT, or Credentialed McKenzie Method PT, I definitely emphasize postural correction and HEP for all spinal patients. I find this works better, not to mention easier for the patient to do than most stabilization programs. If someone gets better without showing them core strengthening or deep cervical flexor exercises, I won't bother with them. If they plateau with only MDT, then I add other approaches. However, the genius of MDT is that it can be done anywhere, and it is VERY effective; if you are assertive enough to make a patient understand not only that they need to do it, but WHY they need to. It can make them better, and once it does, it can prophylacticly keep them better. These exercises initially need to be done 10 reps an hour as a generic example to start.

The failure of most PTs, some of them even Cert's is that they don't make the patient understand they need to get to end range, whether it's cervical, thoracic, or lumbar. The patient will often say they tried the exercise, but it hurt to do it, so they stopped. Maybe it hurt, but did it make them worse? Worse is only if it increases during the motion, and REMAINS worse. Ironically, I am the best example of this. I wake a few times a year with a cervical derangement or acute facet lock (whichever you prefer, to me they're the same thing, different name). If someone I was training was good enough to manipulate me, great! I'd gladly accept one, and continue with cervical retractions. Two years ago, this happened to me, and none of my current students were proficient using their left hand. I really needed a lower cervical translatory thrust as I had acutely painful sidebending and rotation to the left, and extension was also blocked. Cervical retraction and extension exercises were painful, but did not make it better.

At this time, I just happened to be attending a McKenzie Clinical Skills Update course. The instructor was saying to try cervical retraction with SB and overpressure. I thought, what the hell, "end range is where the magic happens!" I retracted and pulled to the left, harder and harder, moving further and further. At first, it hurt like hell! It did not REMAIN worse, but really didn't change for the first 2-3 hours. Then it happened, it gradually got easier. I began to pull even further into end range sidebending left, so much that my right upper trap felt like I was tearing it. After several hours of doing this exercise 30-40 times/hour. I was nearly pain free and most of my motion had returned.

Would a cervical thrust manipulation do the same thing? Absolutely! Would it have been easier on me as a patient? Sure? Would most patients go nuts into the painful/obstructed direction like I did? Most likely not, they would think they're injuring themselves, when in reality, they don't give it enough time, force, and repetitions.

Where manipulation comes in is for the patients who can't push themselves. A recent award winning JMMT study showed that patients who met the CPR for lumbar thrust manipulation also fit neatly into the lumbar derangement syndrome category. Well, of course they do! Both can rapidly change! I'm sure if the same methods were applied for cervical derangement and the CPR for thoracic/cervical thrust manipulation, the same would hold true. Manipulation makes the derangement more easily reduced by the patient. If their exercises are less painful, you'll have more compliance. In my experience, it doesn't make them any more reliant on you, and they still get discharged within that magic 6-8 visits for most acute conditions.

Treating two of these cases right now. Great article on another blog, The Manual Therapy Mentor, regarding concussions and manual therapy. I have found many of the same findings. Certainly many of the HA concussion patients have are caused by post-concussion syndrome, but after head/neck trauma, why wouldn't they have upper cervical/subcranial dysfunction.

I hope you guys are enjoying the links to more great articles from the wealth of useful health information out there on the web. It's apparent I'm a big NOI fan. Here's another one on Discs Don't Hurt!

History:
A month ago or so I posted about using the fascialator on a posterior tibial tendinitis patient who is a triathlete. He's well known to me and comes in intermittently with various exacerbations or new conditions which is most likely befitting of his lifestyle. Most of the time his problems are ITB related with a loss of hip IR and gluteus medius weakness. He developed pain while swinging a bat from mid-swing to follow through. His pain occurred in his right inguinal area and proximal hip flexors and only with this motion. It was limiting his hardball performance. It was acute in nature and this was the only thing that reproduced it.

Objective:
limitation of bent knee fallout (FABERs) but strangely enough had full hip IR.
lumbar screen was negative for Sx reproduction, but he had limited L5-S1 rot left in springing and with a lower trunk rotation test (hooklying and dropping legs to left and right to see if one side has limited rotation). The right side was more limited (scapula rose earlier) but with no pain
Palpation revealed: severe restrictions in right QL, and psoas, proximal ITB was also limited in proximal to distal direction and transverse muscle play.

Treatment:
QL Release

performed in sidelying with contact point behind midline and between 12th rib and superior iliac crest, starting with oscillations and then progressing to functional release of patient repeatedly moving right UE into elevation.

Psoas Release

Performed in supine with hips/knees flexed. 2-3" lateral to umbilicus and pushing slightly medial and posteriorly until you come to a stop, but not so medial you feel a pulse. AROM hip flexion should make the psoas palpably contract. Started with oscillations and progress to heel slides as a functional release.

Lumbar spine was rechecked, but still limited. A lumbar thrust manipulation in rotation was performed bilaterally.

Finally, some TASTM to the proximal ITB where palpably restricted was performed.

After these treatments, the patient was able to perform the swinging motion completely pain free. He was instructed on QL and psoas stretching for HEP.

Discussion:
You could make the argument that I should have retested the batter's swing after each treatment, but time is limited and I wanted to get everything in one treatment. His hip ER was limited by restricted psoas, thus causing his lumbar spine to over-rotate and further straining his hip. The lack of ER was also causing excessive hip hiking, closing down right lumbar spine and shortening his R QL. Restoration of hip ER with psoas release, and release of QL and ITB, plus a lumbar thrust manipulation for good measure restored his mechanics and prevented hip/lumbar strain. He was to follow up by text or email and would only schedule if another visit was needed. Thus far he is still doing well.

As always a great read by the NOI Group on their NOI notes page. It discusses the potential links between spirituality and nerve root pain. Check it out, I know in my practice and experience, factors like this make a difference.

Great article on the relationship between chronic pain, low mood and catastrophising. Nothing that wasn't apparent, but good to see more research being doing in this area. Even better read if you're taken David Butler's courses!

Last summer I started getting regular referrals from a local podiatrist. It was a refreshing change from my regular caseload of chronic craniofacial, headache, cervical and lumbar pain. I have treated plantarfasciitis before with good outcomes, but not since I regularly started using the fascialator for TASTM. Here are the common dysfunctions you should look for

Soft Tissue Restrictions
1) tenderness and restriction along the plantarfascia in a distal to proximal or proximal to distal direction.
This often feels like rice crispies and more so than other areas of the body (except thoracolumbar fascia and/or ITB)

2) along the bony contours of the superior medial and lateral calcaneal borders
this is often tender and restricted, limited calcaneal rocking and tilting

3) the proximal lateral posterior calf - pt's with lower quarter muscle imbalances often have a restriction here, and it can refer distally into the foot, plus limit dorsiflexion

Joint Restrictions
1) the talocrural joint is normally restricted in posterior glide, and more often than not, the medial portion of the talus is not moving posteriorly, but the lateral is. This causes toe out and compensatory overpronation, overstretching the plantarfascia during stance phase

2) the lack of dorsiflexion and the "too many toes sign" then lead to a decrease or complete lack of push off with the first ray, the longer this goes on, the more likely the restrictions in great toe extension, which should be up to 90 degrees passively

3) the subtalar joint may be restricted in medial/lateral tilt, upward rotation (dorsiflexion osteokinematically), or internal/external rotation (vertical axis)

Suggested Treatment
1) Functional Release and TASTM to the plantarfascia

 2) Functional release and TASTM to the posterior calf

3) some finishing touches of TASTM/functional release to the bony contours of the calcaneus to free up calcaneal rock

4) joint distraction and posterior glides to the talocrural joint, thrust as a progression for distraction
also remember to restore great toe extension with 1st MTP distractions and posterior glides if necessary, this will make #6 easier on the pt, thus increasing compliance.

5) home program of runners stretch with an emphasis on heel pushing into the ground and forward facing foot - no too many toes sign allowed!

6) the KEY to the home program is the The Strassburg Sock
If a patient wears this nightly, it will keep them in dorsiflexion and most importantly continue to activate the windlass effect which will keep their plantarfascia on stretch. They have to wear it at least 6 hours!

7) Progress on TASTM and joint mobilization - they should be better within 6 visits no matter how chronic their condition was!

Here are a couple of instruction videos for the lumbar roll "kickstart" variation. After studies came out showing specificity wasn't needed, I started using first the SI gapping technique from the CPR for Lumbar Manipulation and then moved on to this technique, which I find easier and more comfortable for the patient. Hope you find the videos useful!



This is a variation for patient's with hip hypermobility. They can be difficult to get leverage on!



Hope you find these helpful! Please comment or question below!

First in a series of courses at D'Youville College that will hopefully start up their certificate in Orthopaedic Manual Physical Therapy. Partnered with Learning Partners, a local con-ed company, both students from other schools, licensed PTs and DYC students may all take the courses! Here's one of my favorite videos. Blog and youtube channel will be updated later with more footage with better and longer examples and explanations for spinal manipulation. Thanks for reading!

If you haven't checked out any of NOI group's courses, you absolutely should. David Butler and his colleagues really put on a great course. They also have a good regular newsletter. Here is a good post by Adriaan Louw.

The Golden Click

A patient's close friend was suffering from dizziness for years. She referred her to my practice. She was seeing a local specialist who was medicating her and giving her upper cervical injections (she wasn't sure what kind) monthly. This went on for years with no change. One scary aspect of her case was that she had difficulty driving and she was a bus driver in my local school district!

History

She presented as a pleasant female in her mid 50s, endomorphic with fair sitting posture, protracted shoulders, forward head (of course). Her main complaint was constant dizziness and feeling lightheaded. She also c/o HA and cervical pain L > R radiating to upper traps. Symptoms were worse in the morning, at night, with prolonged sitting and driving.

Objective

Cervical flexion WNL, cervical extension showed moderate loss and pain during motion. Cervical rotation was limited severely bilaterally with hard end feels. Cervical SB was limited severely L > R. Passive intervertebral motion testing revealed severe restrictions in OA bilaterally, severe restrictions in C2-4 downglide L > R. Myofascia was L > R severely restricted along the occiput laterally to medially, and along paraspinals and upper traps proximally to distally. L > R 1st rib was grade 2 for inferior glide.

Discussion: I didn't perform special testing as I don't find it useful. She did not have any trauma and did not have enough restrictions in motion as to appear unstable. Vertebral artery testing is not reliable. I could have tested for BPPV, inner ear dysfunction, etc, but I thought it was cervicogenic based on her very limited cervical ROM and passive accessory motion.

Treatment: Tool Assisted STM to cervical paraspinals and upper traps

Rocabado "skull crusher" shear for OA distraction, this is an extremely effective technique for subcranial dysfunction and OA FB limitation. Great for cervicogenic HA as well. It will get it's own blog post soon.

TASTM was also performed to the upper traps

Home exercises were cervical retraction to be performed hourly, and scapula setting to restore upper quarter  posture. She purchased a lumbar roll for use in all sitting positions.



In one treatment, her dizziness, which was constant had decreased by 75%. Her active ROM in rotation improved by at least 20 degrees in both directions. She was completely symptom free by the 3rd treatment. We kept treating her using TASTM to her cervical paraspinals, upper traps, added first rib non-thrust manipulations. HEP was not changed as she was still symptom free for her last visits. She was treated in all 6 visits, the last of which was two weeks after the 5th. She had near full ROM in all planes, including extension with no reproduction of any dizziness, HA, or cervical pain. She was very pleased, and we were both relieved that school kids were no longer in danger of the dizzy bus driver!

Just wanted to repost this great article by of the practitioners that got me into looking more at Fascia. Dr. Leon Chaitow. Please check out his blog and website, very informative!

Chaitow's Chat

After taking David Butler's Courses in 2002, I was all about neurodynamics! I had always used "nerve stretching," but not to the extent I did for the next 2-3 years. Everyone received them as patients! Whether or not there was referred or radicular complaints!

A few years before that, when I was studying at the University of St. Augustine, I wrote in a case study that I was doing an upper limb tension test. Dr. Patla asked if it was only for provocation testing, because "you should never stretch a nerve." I replied yes, only because I was doing it for testing, and as it was a current patient, I stopped doing it as treatment. A little white lie.

Over the years, I have definitely found uses for neurodynamic tensioners (current term for nerve loading or stretching). For example, chronic medial and lateral epicondylagia that didn't respond to the traditional treatments, and persistent leg pain/paraesthesia that didn't centralize with MDT. They are also useful to show someone for home exercises.

Conversely, as I got into more tissue work, both functional and tool assisted, I found myself using them only during evaluation. For example, on a patient with chronic lateral epicondylagia, I would test radial nerve, find a limitation, maybe at the elbow, forearm, wrist, or all of the above. I would take a functional measure next, possibly grasping with or without elbow movement. I would then perform some TASTM on the bony contours of the radius, both posteriorly where the symptoms are, AND anteriorly. Maybe some radial head lateral glide (MWM) and/or thrust like Mill's manipulation would also help. Function and radial nerve neurodynamics were then retested. More often than not, it would be better. The  neurodynamic tensioner was instructed as a home stretch to be performed 5-7 times/day, for 2-3 sets of thirty second oscillations.

As treatment your choices are this...

Use neurodynamics as tensioners to those who can tolerate them (stretching)

• oscillate at different joints, shoulder depression, shoulder ER, elbow extension, forearm supination, wrist extension for median
• hip flexion, IR, adduction, knee extension, ankle dorsiflexion for sciati

Use neurodynamics as sliders (proximal component is slacked to enable more distal movement)

• median: head bent toward, then shoulder abduction to 60
• full shoulder ER, elbow extension, FULL supination, wrist extension
• sciatic: head extension in supine or slump (may also sit upright)
• hip flexion, IR, adduction, knee extension, ankle dorsiflexion

use neurodynamics as pre-test and post-test, treat the neural container

• screen all adjacent joints along the path of the nerve
• perform STM/TASTM along areas of dysfunction
• retest after treatment

as a progression for step 3

• combine and "get jazzy" as Butler would say
• put someone in neural load, i.e. median stretch
• perform wrist mobilization P/A for extension in load
• perform TASTM to anterior forearm or medial upper arm in load

If you choose steps 1-2 and be a "nerve head" or 3-4 and only use it as testing, you will find many patients that you can help with chronic conditions. Questions? Comments? I'll be posting some videos of examples this week. Be sure to check out the OMPT Channel and subscribe for notifications!

Median Neurodynamics


Radial Neurodynamics


Ulnar Neurodynamics


Sciatic Neurodynamics


Femoral Neurodynamics