Many therapists agree that there is no single 'best posture.' Most would also agree that we do not have 'dysfunctional movement,' but rather movement deviations. As I tell many of my patients, "No movement is a bad movement; no posture is a bad posture. To live fully, we must perform them all." Therefore, movement habits and patterns do not equate to pain. While I agree with this philosophy, we simply cannot neglect posture and movement. As physical therapists, our job is to identify positions of relief to calm down the system & provide novel stimuli to reprogram the system. In this post, I discuss my personal experience with low back pain. I discuss my assessment and treatment from a movement perspective and pain perspective. 

Last year I was experiencing mild to moderate right sided low back and right anterior hip pain that would increase while performing lat pull downs and back squats. Symptoms increased at the end-range of the concentric phase of the lat pull down and deep in the squat position. I would describe the pain as compression and pinching in both the low back and anterior hip. Out of curiosity, I took pictures (see below) performing these movements to see what was occurring mechanically.

Picture Analysis

• Hinge point in R low back at L2 region with side bending
• Excessive lumbar flexion with forward trunk positioning during the squat
• Hinge point at L2 region during lat pull down

While hinge points are common and not correlated with pain, I happened to have a hinge point at the location of my low back pain during the lat pull down. This skin fold appeared because I would hyperextend through the thoracolumbar junction during lat pull downs. As seen in the squat photo, I had considerable lumbar flexion, forward trunk positioning, and out-toeing bilaterally.* If I performed an abdominal draw in maneuver (emphasizing TrA) during any of these movements, I felt significant relief of symptoms** While I did not have any EMG done, it felt as if the lower abdominal activation allowed my anterior hip flexors to 'turn off' relative to their previous state.***

*Do not worry pain scientists, I know we naturally flex through the lumbar spine and some people naturally lean more forward depending on their tibia to femur ratio.
**Do not worry global strengthening folks, I know there is no evidence to support TrA activation.
***I won't get into the topic of inhibited vs. facilitated muscle groups in this post.

Personally, I chose to perform a combination of both options.
My top 3 interventions:

1. Lumbar extensions
2. Hip external rotation mobility
3. Thoracic mobility. ​

1) Lumbar extensions were performed to improve lumbar extension range of motion as well as improve the loading pattern into extension as I squatted. While the first few repetitions were painful, the repeated loading desensitized movement and allowed me to maintain an upright position in the squat. 
2) Hip External Rotation mobility was performed to improve the joint mobility in my hips. I perceived that tight hip joints were limiting my capacity to squat. From a mechanical standpoint, improved hip mobility allowed me to disassociate lumbar motion from pelvic motion. The increased hip mobility allowed me to maintain a neutral spine position and load through the posterior chain.
3) Thoracic mobility was performed to help maintain an upright posture during squatting movements and allow for improved shoulder mobility while performing lat pull downs. Additionally, improved thoracic mobility gave me a sense of better scapular muscle activation. ​

In my situation, combining my knowledge of pain and tissue damage with the more mechanical approach of proper alignment was very effective. Since the brain is the control center of all input and output, it recognizes when someone is using too much energy to perform a task. For example, the forward head posture is not inherently painful, but chronic forward head positioning is an inefficient use of energy. To hold the head in a forward position, the anterior and posterior muscles are not working in equilibrium. The brain must expend more energy, time, and attention to keeping the head in a forward position. It has nothing to do with pain, and everything to do with efficiency. The combination of approaches was beneficial because I brought awareness and perception to areas that needed stimulation, and simultaneously calmed down areas that were already too sensitive to movement. 

​In conclusion: the treatment approach will be different for everyone. We all think, move, and act in unique ways. Many of our daily actions are performed reflexively without thought or awareness. Bringing increased perception to a painful region while modulating their pain will allow someone to understand why the pain is occurring and how to control symptoms.

Core strengthening appears to be a very abstract term in the world of physical therapy. To some, it means very specific motor control training. To others, it means planks. Several years ago, a proposed core stabilization clinical prediction rule was shown to lack validity. Regardless, due to the lack of established guidelines for core stability training, there will continue to be a variety of techniques, based on the clinician's preference.

​When it comes to lumbar manipulation, there has been a significant amount of research to show our inability to manipulation a specific segment. Even when we try to "isolate" an area, movement can occur several segments above and below. It would appear the lack of specificity with manipulation is rather insignificant, so certain patients may just respond to manipulation in general. Can the same theory apply to stabilization? I recently read a study that compared specific motor control training in the lumbar spine to high-load deadlift training. The results showed that there was no difference in strength, pain intensity or muscle endurance between the two groups. The motor control group did have better motor control and activity, but the fact that pain, strength, and endurance were similar can help us in not needing to be so specific with our exercises. Sometimes, the particular instructions we give to our patients can actually cause a fear of movement, which is something we want to avoid.

Now, I am not necessarily saying there is no point to motor control training. I would simply argue that it's not as important as we used to think. If there is a subtle pelvic motion when reaching overhead, we don't necessarily need to be stopping the exercise altogether. It may still be beneficial to establish some general patterns of motion during earlier stages of rehab in order to prevent re-aggravation during high load training. Personally, following my manual treatment (if indicated), I will start with a  couple mobility exercises to help get the spine moving. I then follow that up with some motor control training to prep for whatever movement I am going to have the patient perform. For example, if my patient will be doing a deadlift, I will prime them with a quad rock back and/or hip hinge, in order to help dissociate lumbar and hip motion with heavy lifting. My end-goal however, is to get my patient strengthening with heavier weight.

​-Dr. Chris Fox, PT, DPT, OCS

Looking for advanced sports and orthopedic content? Take a look at our BRAND NEW Insider Access pages! New video and lecture content added monthly. 

Cervical stability testing is one of the most important aspects of a cervical screen. While it may not help our treatment directly, it may save some people's lives or prevent significant worsening of injury. There are several key components of cervical stability testing:
​-Transverse Ligament
-Alar Ligament
​-Fracture Screening
​There is specific testing for Alar Ligament Integrity but for cervical fx screening, it is recommended to utilize the Canadian C-spine rules and Jefferson Fx test.

​The Transverse Ligament is responsible for maintaining stability between C1 and the odontoid process of C2. Without the ligament functioning, spinal cord injury is possible. While it is rare for a patient with a ruptured Transverse Ligament to present to you in a clinic, with direct access, it is certainly possible. The patient may hold their head in a certain position (avoiding positions that aggravate symptoms), to keep the injury "reduced." There are two methods that we recommend for testing the ligament's integrity: Sharp-Purser Test and Supine Transverse Ligament Test.

While both tests can be effective for assessing stability, we recommend using both. First, the Sharp-Purser Test should be used as it is a REDUCING test. That means, if a symptomatic patient presents, you will reduce their symptoms if the test is positive. While most patients won't allow you to "provoke" their symptoms with the initial part of the test, it is still important to try reducing symptoms before aggravating. Next, we recommend using the supine Transverse Ligament Test to provoke symptoms. The force is minimal, so it is unlikely to be harmful if stopped when any appropriate symptoms are produced.

​While the diagnostic accuracy for upper cervical stability and utilization of Canadian C-Spine rules is relatively high, it is not recommended to completely override clinical decision making. As always, we recommend a thorough evaluation and consideration of the evidence of each test's findings. For more information on these tests, be sure to check out the pages linked above.

​-Dr. Chris Fox, PT, DPT, OCS

Looking for advanced sports and orthopedic content? Take a look at our BRAND NEW Insider Access pages! New video and lecture content added monthly. 

In honor of National Physical Therapy month, The Student Physical Therapist has compiled a list of facts, statistics, and fun information about our amazing profession. This quiz covers everything from historical facts about Physical Therapy to Physical Therapists perception on the dating app Tender! 

We hope you enjoy the quiz! Please continue to strive everyday to make the profession great. 
#getPT1st
​Jim, Chris, and Brian