What Is Wrong With this Movement?

I have been treating the individual in the picture to the left for 4 visits following a forward bending injury. After 4 visits he has reported 90% improvements in pain and function. His treatment sessions have focused on neutral core posture with hip strengthening & retraining his squat, deadlift, and reaching patterns. On the date of this photo, he is no longer having low back pain, but complains of lower thoracic spine pain.

What do we see from the picture?
First, he is lacking forward flexion active range of motion. He should be able to touch his hands to the floor when bending forward. Second, he does not have a uniform spinal curve. Almost all of his movement is coming from his thoracic spine. The large hump in the middle back is a good indication that the lumbar spine is not flexing! In addition the location of his pain is at the transitional zone from the thoracic spine to the lumbar spine (TL Junction). Finally, this individual does not translate his hips posteriorly at the proper time. In the photo, some posterior hip translation is noted; however, this movement only occurs after the thoracic spine has ran out of room to move. Normally, an individual should lead the movement from their hips.

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The Treatment
1) Due to the location of pain, my first intervention was a middle and lower thoracic manipulation in supine (see video on the right).
2) Next, I performed a prone lower trap + thoracic extension exercise to promote thoracic extension while engaging the scapular muscles. One can imagine this individual lacks scapular stability based on the position of his thoracic spine. If he was lifting from this position, something has to give. In this case, it was his low back. 
3)Third, prone T's exercise with abdominal activation were prescribed to promote more scapular activation from a neutral spine.
4) Fourth, I gave supine bridges + mini march while keeping the core in a neutral position. This exercise was a progression of his bridges from a previous session.
5) Fifth, I had him perform theraband lat pull downs from a partial squat position. With this exercise, the individual continually needed cueing not to flex from the thoracic spine. With manual and tactile cues, he could control the movement. 
6) Finally, I worked on retraining his hip hinge pattern using a stick along his spine.

​Conclusion
​How our patient's move gives us so much information about their pain. At the end of the treatment, he could bend forward about 50% further with an improved uniform spinal curve. A key point to note: I did not directly work on his lumbar AROM, but by providing stability and motor control to the thoracic spine, his lumbar range of motion improved. This treatment session is a great example of the necessity to treat the area of dysfunction not pain!

​Jim 

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