National Orthopaedic Division of the Canadian Physiotherapy ...

CANADIAN PHYSIOTHERAPY ASSOCIATION

ADVANCED INTEGRATED MUSCULOSKELETAL PHYSIOTHERAPY PROGRAM

POLICIES AND PROCEDURES EDUCATION AND EXAMINATION STANDARDS

DOCUMENT

CURRICULUM DECEMBER 2016 JANUARY 2020

CPA Advanced Integrated Musculoskeletal Physiotherapy Program: Policies and Procedures– Education and Examination Standards Document: Curriculum January 2020

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CPA DIPLOMA OF ADVANCED ORTHOPAEDIC MANUAL AND MANIPULATIVE PHYSIOTHERAPY POLICIES AND PROCEDURES EDUCATION AND EXAMINATION

STANDARDS DOCUMENT - CURRICULUM CONTENTS PAGE History of the Diploma of Advanced Orthopaedic Manual and Manipulative Physiotherapy 3 Curriculum of the Diploma of Advanced Manual And Manipulative Physiotherapy 5

I. Purpose 5 II. Policies and Procedures Governing Courses 7 III. Curriculum Continuum Flowchart 8 IV. Policies and Procedures Governing Clinical Mentorship Requirements 9 V. Hours of Instruction and Examination 9 VI. Recommended Course Content 10

Level 1 - Peripheral & Vertebral Course Curriculum 10 Level 2 Lower Quadrant Course Curriculum 24 Level 2 Upper Quadrant Course Curriculum 34 Level 3 Lower Quadrant Course Curriculum 44 Level 3 Upper Quadrant Course Curriculum 52 Level 4 Vertebral Joint Course Curriculum 58

Level 5 Vertebral Joint Course Curriculum 61


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HISTORY OF THE CANADIAN DIPLOMA OF ADVANCED ORTHOPAEDIC MANUAL AND MANIPULATIVE PHYSIOTHERAPY

Please refer to the following documents available from the:

Canadian Physiotherapy Association National Office 955 Green Valley Crescent, Suite 270 Ottawa, Ontario Canada K2C 3V4 Phone: (613) 564-5454 or (800) 387-8979 Fax: (613) 564-1577 Email: [email protected]

Canadian Physiotherapy Association: Proposed Vision for Manual Therapy Education

Manual Therapy Steering Committee: Proposed Vision for Manual Therapy Education

College of Physical Therapists of Alberta: Competencies Required to Safely Perform Spinal Manipulation as a Physical Therapy Intervention

College of Physical Therapists of Ontario: Controlled Acts

International Federation of Orthopaedic Manipulative Physical Therapists: Standards Document

The development of the Canadian Manual therapy system parallels the formation of IFOMPT. Amongst the first of our Fathers of Manual therapy were David Lamb, John Oldham and Cliff Fowler.

◊ 1973 – Canary Islands: As part of the development of the International Federation of

Orthopaedic Manipulative Physical Therapists (IFOMPT) a special meeting was held where 74 manual therapists from around the world attended workshops over a period of 4 weeks. In the end an examination in manual therapy theory and techniques set by Drs. Cyriax, Brodin, Stoddard, and Frisch examined participants. David Lamb, John Oldham and Cliff Fowler were the Canadians who passed the exam. Upon their return to Canada, they began teaching manual therapy techniques across the country marking the beginning of the Canadian Manual Therapy program.

◊ 1974 WCPT in Montreal: The Canadian Physiotherapy Association (CPA) voted to allow

the formation of the Orthopaedic Division (OD).

◊ 1978: Canada became an associate member of IFOMPT and ran it’s first certification examination using international standards. These exams were named the Part A and B examinations. The Part A examined manual therapy theory, clinical reasoning, mobilization and peripheral manipulation.

The Part B exam was a practical examination on spinal manipulation. The exams were set in these two parts to allow candidates to split up the demanding process, and to allow individuals not interested in spinal manipulation to acquire theory in manual therapy.

◊ 1983: Manipulative therapists passing the Part B exam at the first orthopaedic division national conference in Victoria, BC, established The Canadian Orthopaedic Manipulative


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Physiotherapy (COMP) group. The intention of COMP was to provide an informal exchange of clinical experiences and knowledge between individuals who had demonstrated the greatest degree of clinical competency through examination available at that time. This group also acted as Canada’s representative body to IFOMPT.

◊ 1984 IFOMPT meeting in Vancouver, Canada: Canada became a full voting member of

IFOMPT ◊ 1985: CPA first approved the curriculum of the OD. This marked the birth of its educational

system of manual therapy courses. The curriculum was amended in 1986, and revamped from 1997-1999 to become a 5 level system of courses leading to a Diploma of Advanced Orthopaedic Manual and Manipulative Therapy. There was a significant curriculum revision and update completed in 2005 with an increased emphasis placed on evidence informed practice and clinical reasoning and a multimodal approach to manual therapy.

◊ 1995: The Canadian Academy of Manipulative Therapists (CAMT) was formed. CAMT is

the direct offspring of COMP and thereby replaced COMP. CAMT was voted to become a formal academy with a constitution and a more focused approach to clinical manual therapy.

◊ 2009: The Canadian Academy of Manipulative Therapists was changed to the “The

Canadian Academy of Manipulative Physical Therapists” (CAMPT) in parallel with IFOMPT.

◊ In the following decade, CAMPT, NOD and the CPA Orthopaedic Division’s education system successfully completed two International Monitoring Submissions, ensuring that this program met or exceeded standards required to remain an internationally recognized educational program and that graduates held an internationally recognized credential.

◊ 2020: The educational program offered by the OD was rebranded to be the Advanced Integrated Musculoskeletal Physiotherapy Program (AIM) / Programme Integree de physiotherapie musculosquelettique avancee. Along with the rebranding, the curriculum was revised and the manuals updated to reflect current evidence informed practice. They have been formatted into e-books and will be living documents improving the dissemination of information and translation of new evidence on a regular basis.


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CURRICULUM OF THE CPA DIPLOMA OF ADVANCED INTEGRATED MUSCULOSKELETAL PHYSIOTHERAPY PROGRAM

I. PURPOSE The purpose of the curriculum of the Orthopaedic Division of the Canadian Physiotherapy Association is to provide direction for the development of Advanced Integrated Musculoskeletal Physiotherapy Program Courses which are aimed at producing evidence informed and skilled manual orthopaedic physiotherapists who will achieve a Diploma in Advanced Integrated Musculoskeletal Physiotherapy. The Advanced Integrated Musculoskeletal Physiotherapy Program Courses are designed to be a continuum of learning with evaluation from the start of the Level I course to the completion of the Level V course and subsequent Advanced Integrated Musculoskeletal Physiotherapy Examination. Successful completion of this final examination qualifies the graduate for membership in CAMPT and recognition by IFOMPT. The framework of the curriculum provides for regular review and updating in order that subsequent course development will be consistent with an established body of knowledge, with current professional standards of practice and accepted professional ethics.

The Diploma of Advanced Integrated Musculoskeletal Physiotherapy Program Curriculum, as presented, outlines the minimum requirements for courses which are designed to prepare a candidate for each level of the Diploma of Advanced Integrated Musculoskeletal Physiotherapy certification. It also requires that candidates develop self-reliant learning strategies which will be directed towards continued self-development. The intention is to develop skilled, reflective practioners and expert evidence informed clinicians. Courses taught following the guidelines established by the Orthopaedic Division will be aimed towards preparing candidates for each level of the Advanced Integrated Musculoskeletal Physiotherapy Program and subsequent Diploma of Advanced Integrated Musculoskeletal Physiotherapy. The major objectives of the curriculum fall broadly under three areas:

A. Information and knowledge B. Skills C. Attitudes

It is not the intent of the curriculum to breach intellectual content issues of the various parties that may be mentioned in the document. Rather it is to ensure that the students have been exposed to the general concepts regarding this information. It is advised that if the student desires more information on any specific topic, that they augment their learning with additional research in the form of reading and / or course work.

All successful examination candidates of each course level, as well as the final Diploma of Advanced Integrated Musculoskeletal Physiotherapy, will have demonstrated ability and competence in using the curriculum major objectives to problem solve and in the application of critical reflection. Specific Advanced Integrated Musculoskeletal Physiotherapy Program - Course objectives have been developed, are consistent with the overall broad objectives, and take into account the content and scope of the examinations as set down in the Curriculum.


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Candidates will meet the following objectives with regard to the curriculum for Advanced Integrated Musculoskeletal Physiotherapy Program – Course Level prior to becoming eligible for each subsequent level of certification.

A. Information and Knowledge 1. Demonstrate an integration of evidence informed practice in all assessment and treatment

theory and practical applications. 2. Demonstrate a clear understanding of the detailed structure and function of normal

musculoskeletal tissues. 3. Demonstrate a clear understanding of the contraindications to physical techniques and

procedures commonly used in orthopaedic physiotherapy. 4. Demonstrate an understanding of the diagnosis, prognosis and overall management of

patient problems. 5. Demonstrate an ability to analyze and integrate the various aspects of the required

theoretical knowledge and skills in the overall management of patient problems. 6. Explain the pathophysiology relating to musculoskeletal disorders together with the

resultant functional deficits. 7. Briefly describe the theory of the effects of physical agents used in physiotherapy on

normal and abnormal tissues. 8. Recognize and explain the limitations of specific techniques employed in orthopaedic

physiotherapy. B. Skills

1. Demonstrate an integration of evidence informed practice in all assessment and treatment applications.

2. Select and apply appropriate assessment procedures prior to, during and following treatment.

3. Analyze and interpret assessment procedures in order to identify, prioritize and plan and modify treatment.

4. Records clearly and concisely all assessment findings, treatment(s) performed and reassessment findings.

5. Explain and demonstrate how general and specific management plans, including manipulation, will provide symptomatic relief and restoration to optimum function.

6. Explain and instruct in the proper use of body mechanics in both therapeutic and prophylactic situations.

7. Identify patient’s diagnosis, special problems, nature and extent of dysfunction, cause, contributing factors and generally related problems, to establish an appropriate management plan.

8. Identify the need for additional referral/assessment/consultation. C. Attributes

Develop self-reliant learning strategies directed towards the maintenance and improvement of both knowledge and skills.

D. Required Levels of Instruction

The required levels of instruction for the Advanced Integrated Musculoskeletal Physiotherapy Program - Courses are detailed in the Curriculum Content and are in accordance with the IFOMPT Standards Document.


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II. POLICIES AND PROCEDURES GOVERNING COURSES

1. All Advanced Integrated Musculoskeletal Physiotherapy Program Courses and Examinations will follow the guidelines outlined in the CPA Diploma of Advanced Integrated Musculoskeletal Physiotherapy Program Policies and Procedures Education and Examination Standards Document, including the Curriculum/ Instructors/ Provincial Orthopaedic Division Course Representative (PODCR) Handbook/ Examinations/ Education Committee / Transition Policies.

2. All courses offered must be consistent with: a. an established body of knowledge; b. current professional standards of practice; c. accepted professional ethics.

3. Courses must be taken in a specific order, outlined in the C.P.A. Diploma of Advanced Integrated Musculoskeletal Physiotherapy Program Policies and Procedures – Education and Examination Standards Document – Curriculum (see the Curriculum Continuum Summary Flowchart on the next page).

4. A full course of study, by definition, includes all course levels and appropriate examinations of

the Diploma of Advanced Integrated Musculoskeletal Physiotherapy Program and fulfills the total objectives and content of the Diploma Advanced Integrated Musculoskeletal Physiotherapy Program – Curriculum.

5. Courses may be offered on a full time or part time basis. 6. Advanced Integrated Musculoskeletal Physiotherapy Program Courses are open to all

physiotherapists who fulfill the registration requirements for the course level in question. 7. Due to the rate of rapid change in the supporting literature for musculoskeletal physiotherapy, it

is recommended that the maximum time duration between courses not exceed 5 years. 8. All Advanced Integrated Musculoskeletal Physiotherapy Program – Courses must be organized

by the Provincial Orthopaedic Division Course Representative unless written permission has been obtained from the Orthopaedic Division Education Committee Executive.

9. Course organizers/instructors have a responsibility to ensure that any proposed Advanced

Integrated Musculoskeletal Physiotherapy Program Course fulfills, in whole, the objectives of the Advanced Integrated Musculoskeletal Physiotherapy Program Curriculum and the content and scope of the corresponding Advanced Integrated Musculoskeletal Physiotherapy Program examinations.

10. All Advanced Integrated Musculoskeletal Physiotherapy Program Courses offered must:

a. accurately reflect the title of the course; b. clearly state the purpose and objectives of the course; c. clearly state the preparatory reading material; d. clearly state the format and content of examinations or quizzes; e. clearly state the appropriate reference list; f. clearly describe the course content.


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III. CURRICULUM CONTINUUM FLOWCHART


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IV. POLICIES AND PROCEDURES GOVERNING CLINICAL MENTORSHIP REQUIREMENT

Clinical practice is an essential and integral part of the curriculum. Candidates are required to provide evidence to course organizers/instructors that they have undertaken a period of clinical practice mentorship covering the scope of preparatory courses. Please refer to the Mentorship Policies and Procedures document for full details of the mentorship requirements for candidates within the Advanced Integrated Musculoskeletal Physiotherapy Program.

V. HOURS OF INSTRUCTION AND EXAMINATION OF THE DIPLOMA OF ADVANCED INTEGRATED MUSCULOSKELETAL PHYSIOTHERAPY PROGRAM

Each Advanced Integrated Musculoskeletal Physiotherapy Program course outline has a suggested amount of instructional hours beside the breakdown of the topic matter. A combination of any of the following instructional methods is suggested:

◊ Didactic lectures (factual, theoretical) ◊ Audio-visual aids: slides, overheads, videos, anatomical models, manual supplementation ◊ Online audio power point presentations and video lectures. ◊ Synchronous and asynchronous web based e-learning. This applies to theory content and

the research experience component of curriculum. ◊ Mock or live patient case studies and clinical examples using clinical reasoning skills ◊ Self study (pre / during / post course reading) ◊ Practical demonstrations ◊ Examinations

Total Hours of Instruction and Examination of the Advanced Integrated Musculoskeletal Physiotherapy Program Courses – Level I to Level V and the Advanced Examination:

Total Instructional Hours: 456 hours Total Examination Hours: 21 hours Total: 477 hours

Total Hours of Clinical Supervision / Mentorship of the Advanced Integrated Musculoskeletal Physiotherapy Program Courses – Level I – Level V:

Total hours prior to the Intermediate Examination: 90 hours Total hours prior to the Advanced Examination: 60 hours Total: 150 hours

The Orthopaedic Division Executive expects that the candidates of the Diploma of Advanced Integrated Musculoskeletal Physiotherapy will augment the above instruction and examination hours with the following:

◊ Clinical practice ◊ Group study ◊ Online discussion groups ◊ Utilization of a Preceptor / Mentor ◊ Literature review ◊ Participation in research projects

**A typical candidate will spend a minimum of 500 to 1000 augmented hours.

CPA Diploma of Advanced Integrated Musculoskeletal Physiotherapy Program: Policies and Procedures– Education and Examination Standards Document Version: Jan 2020 Level I Curriculum

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VI. RECOMMENDED CONTENT FOR ADVANCED INTEGRATED MUSCULOSKELETAL PHYSIOTHERAPY PROGRAM COURSES

LEVEL 1 - PERIPHERAL & VERTEBRAL COURSE (8 days)

Total Hours: 57 hours (54 instruction / 3.0 examination)

A. PURPOSE:

Course participants will learn and be able to apply clinical reasoning and patient handling skills to perform basic neuromusculoskeletal subjective and objective assessments, and generate a provisional differential diagnoses and treatment plans for musculoskeletal patients.

B. OBJECTIVES:

At the completion of this course, participants will demonstrate competency in:

1. Using clinical reasoning skills in basic neuromusculoskeletal subjective and objective assessment

2. Performing a subjective assessment and identify the nature, severity and irritability of the

patient's pathology 3. Performing an objective neuromusculoskeletal assessment to identify structures that require

treatment or referral for further assessment; including: morphological variances, articular signs, neurological signs, neuromeningeal tests, compression and traction tests, accessory motion testing of the spine, arterial patency tests, peripheral joint screening tests, and basic palpation of articular and soft tissue structures

4. Performing a specific peripheral joint assessment including: observation; active and passive

mobility, muscle length, recruitment, and strength; joint stability; and special tests

5. Integrating into clinical reasoning the principles of selective tissue tension testing including the concepts of: a. inert vs. contractile lesions b. normal and abnormal end-feels c. capsular patterns of restriction d. interpretation of results of resisted testing

6. Integrating into clinical reasoning the organization of the central and peripheral nervous systems, the neurology of joints, and the anatomical bases for nociceptive, peripheral neuropathic, and central pain mechanisms

7. Integrating into clinical reasoning the nature, early signs and symptoms and differential diagnosis of compromise or compression to the central nervous system (brain and spinal cord), and peripheral nervous system (nerve roots, plexuses and peripheral nerves), and the clinical manifestations of pain and dysaesthesias

8. Recognizing non-mechanical disorders of the musculoskeletal system and the presence of

adverse effects or complications of assessment or treatment, and referring and communicating with other members of the health care team


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9. Integrating into clinical reasoning an understanding of evidence informed physiotherapy practice in neuromusculoskeletal assessment and treatment including:

‐ the International Classification of Functioning Disability and Health (ICF) ‐ diagnostic test accuracy and reliability ‐ generic, condition specific and patient specific outcome measures to assess treatment

effectiveness in order to progress or modify treatment ‐ prognostic indicators

‐ principles of wound repair and the role of physiotherapy in this process ‐ level of evidence of treatment techniques

10. Analyzing assessment results to formulate a provisional differential diagnosis and treatment

plan

11. Identifying the indications and/or contraindications to:

‐ neurological testing ‐ neuromeningeal testing

‐ arterial patency testing ‐ joint stability and ligament stress testing ‐ articular mobilizations

‐ deep transverse frictions ‐ traction (mechanical and manual)

12. Utilizing appropriate treatment techniques including:

‐ deep transverse frictions ‐ manual and mechanical traction to the cervical, thoracic, and lumbar spine

‐ spine PA’s – central and unilateral

13. The theory and principles, and patients instruction, for basic spinal exercises and prophylactic care of the back

14. Appropriately appraising a patient's need for a spinal and/or peripheral orthosis 15. Accurately documenting assessment data, findings, problems, SMART goals, and treatment

including elements of informed consent


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C. TOPICAL OUTLINE: 1. Clinical Reasoning:

‐ definition and principles of application

‐ integration of the ICF model ‐ introduction and incorporation of outcome measures: e.g. Neck Disability Index (NDI),

Roland Morris Questionnaire (RMQ), Patient Specific Functional Scale (PSFS)

2. Anatomy, Physiology, & Biomechanics:

‐ musculoskeletal embryology and its clinical relevance: derivation of the mobile segment including myotomes, dermatomes and sclerotomes

‐ basic anatomy and function of connective tissue including ligaments ‐ basic anatomy of the mobile segment ‐ intervertebral foramen boundaries and content

‐ anatomy as required for spinal and peripheral surface anatomy and assessment ‐ anatomy and function of the spinal cord, nerve roots, peripheral nerves, autonomic nervous

system, cranial nerves and neuromeningeal tissue

‐ anatomy and function of the bone, cartilage and muscle tissue ‐ introduction to signs and symptoms of neurovascular compromise of the peripheral and

central nervous system ‐ indications and contraindications for assessment of the neurovascular system

‐ basic anatomy and function, including clinical relevance, of the visceral system ‐ introduction to posture, triaxial compensation and the interrelationship of the functional units

of the body ‐ introduction to tissue mechanics: viscoelastic tissues (types and properties), response of

viscoelastic tissue with age, trauma, overuse, immobilization and during the repair process ‐ introduction to injury and wound healing principles (bone, cartilage, connective tissue,

muscle, nerves) ‐ introduction to Panjabi’s Neutral Zone theory

‐ introduction of motion states: normal / hypomobile / hypermobile / unstable ‐ indications and contraindications of stability testing spinal and peripheral joint complexes ‐ introduction to the biomechanical terminology of osteokinematics and arthrokinematics,

practical examples of each to be shown ‐ introduction to basic spine biomechanics and gait mechanics (see Level 1 gait worksheet)

3. Neurophysiology:

a) Basic mechanisms of nociception:

‐ Transmission ‐ Modulation: inhibitory and excitatory pain control (gate control)

‐ Receptors

b) Introduction to pain mechanisms: ‐ input mechanisms: nociceptive, peripherally modulated neuropathic

‐ processing mechanisms: centrally modulated neuropathic, patient’s perspectives, cognitive / affective influences

‐ output mechanisms: motor and autonomic mechanisms


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c) Introduction to segmental facilitation: normal and dysfunctional including signs of segmental facilitation

‐ sympathetic response ‐ peau d'orange ‐ trophedema

‐ segmental muscle hypertonus, hyperreflexia ‐ hypersensitivity, decreased stimulus threshold

4. Surface Anatomy:

Palpation of spine and peripheral articular and soft tissue structures including bony landmarks, muscle bellies, tendons and insertions, ligaments and nerves, as well as segmental versus multi-segmental muscle tone/fibrosis, temperature, oedema and pulses. a) Lumbo-pelvic Region:

‐ iliac crests ‐ L1 to S4 spinous processes ‐ lumbar transverse processes

‐ lumbar Z joints - erector spinae, multifidus, quadrates lumborum, abdominal, and psoas muscles

‐ sacrotuberous ligament ‐ long dorsal ligament ‐ ischial tuberosities

‐ posterior superior iliac spines ‐ sacral sulci / hiatus / cornu

‐ sacral inferior lateral angle (ILA) ‐ sacrococcygeal joint ‐ sciatic nerve

‐ anterior superior iliac spines (ASIS) ‐ anterior inferior iliac spines (AIIS) ‐ pubic tubercles

‐ symphysis pubis ‐ abdominal aorta pulse

b) Hip:

‐ greater and lesser trochanter ‐ iliopsoas and rectus femoris tendon ‐ psoas and greater trochanteric bursa

‐ inguinal ligament ‐ tensor fascia latae, gluteus maximus and medius, piriformis, rectus

femoris, psoas, adductors, sartorius, hamstrings ‐ femoral triangle and contents

c) Knee:

‐ tibial tuberosity ‐ patella

‐ tibial and femoral condyles ‐ tibiofemoral joint line ‐ fibular head

‐ superior tibio-fibular joint ‐ adductor tubercle


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‐ quadriceps expansions

‐ vastus medialis oblique ‐ iliotibial band ‐ Gerdy’s tubercle

‐ adductor magnus tendon and insertion (adductor tubercle) ‐ infra and suprapatellar tendons ‐ patellar retinacula and patellofemoral ligaments (medial and lateral)

‐ gastrocnemius medial and lateral heads ‐ hamstring tendons ‐ popliteus

‐ pes anserinus tendons and insertion ‐ medial and lateral collateral ligaments ‐ associated bursae

‐ meniscotibial (coronary) ligament ‐ meniscustibial artery

‐ tibial nerve ‐ common peroneal nerve

d) Foot and Ankle:

‐ medial malleolus ‐ lateral malleolus ‐ talus – head, neck and dome

‐ calcaneus – medial tubercle, sustentaculum tali, peroneal tubercle, bursae ‐ navicular - tubercle ‐ cuboid

‐ cuneiforms ‐ metatarsals ‐ phalanges

‐ joint lines: entire foot and ankle including inferior tib-fib joint ‐ tendons: Achilles tendon, tibialis posterior, flexor hallucis longus, flexor digitorum longus,

tibialis anterior, extensor digitorum longus, peroneus longus/brevis, peroneus tertius ‐ ligaments: anterior talofibular, calcaneofibular, posterior talofibular, deltoid (anterior

tibiotalar, tibionavicular, tibiocalcaneal, posterior tibiotalar), spring ‐ dorsalis pedis pulse

‐ posterior tibial pulse ‐ tibial nerve ‐ long saphenous vein

e) Cervical Region:

‐ occiput ‐ external occipital protuberance

‐ superior nuchal line ‐ mastoid process

‐ zygomatic bone and arch ‐ temporomandibular joint ‐ mandible and angle of the jaw

‐ posterior arch of atlas (C1) ‐ C2 –7 spinous processes ‐ C1-7 transverse processes (anterior, lateral and posterior aspects)


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‐ C6 anterior tubercle

‐ C1-7 articular pillars ‐ first rib ‐ hyoid bone (C3)

‐ thyroid cartilage (C4/5) and notch ‐ cricoid cartilage rings (C6) ‐ posterior sub-occipital muscles

‐ sternocleidomastoid, scalenes, upper trapezius, splenius, and semispinalis capitis/cervicis muscles

‐ posterior triangle of the neck ◊ bounded by posterior border of SCM, anterior border or trapezius, and the clavicle ◊ contains scalenus anterior and medius, and brachial plexus

‐ supraclavicular fossa ‐ superior (C1/2), middle (C6), and inferior cervical ganglia (T1) ‐ carotid pulse

f) Thoracic Region:

‐ T1 to 12 spinous processes and transverse processes ‐ ribs 1 to12 shafts and ribs 1-10 angles

‐ manubrium ‐ sternum, ridges and suprasternal notch (T2) ‐ xyphoid process

‐ manubriosternal joint (sternal angle) (T4) ‐ infrasternal angle (T9) ‐ ribs 1 to 7 sternochondral joints

‐ ribs 1 to 10 costochondral joints and costal cartilage ‐ ribs 1 to 12 intercostal muscles

‐ pectoralis major and minor, latissimus dorsi, serratus anterior, abdominal, erector spinae, and segmental spinal muscles

g) Shoulder Girdle:

‐ humerus – head, greater and lesser tuberosities / bicipital groove ‐ glenohumeral joint line

‐ clavicle ‐ acromioclavicular joint ‐ sternoclavicular joint

‐ scapula – acromion process, superior and inferior angles, vertebral border, spine, infraglenoid tubercle, and coracoid process

‐ axilla – anterior fold, posterior fold, medial wall ‐ biceps - long head tendon, short head origin

‐ origin, bellies, insertions of the rotator cuff muscles ‐ pectoralis major and minor, latissimus dorsi, deltoid, biceps, triceps, serratus anterior,

levator scapula, trapezius, rhomboids, coracobrachialis

‐ transverse humeral, costoclavicular, coracohumeral, coracoacromial, coracoclavicular ligaments


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h) Elbow:

‐ lateral epicondyle, common extensor tendon, supracondylar ridge and muscle origins (humerus)

‐ medial epicondyle, common flexor tendon and muslces, and supracondylar ridge (humerus)

‐ cubital fossa (humerus) ‐ olecranon fossa (humerus)

‐ ulna - olecranon process, bursa, triceps and anconeus insertions ‐ radius – head ‐ radio-humeral, superior radio-ulnar, ulno-humeral joints

‐ biceps tendon and aponeurosis ‐ brachioradialis muscle and tendon

‐ brachialis, triceps, anconeus, supinator, pronator teres muscle ‐ medial and lateral collateral ligaments ‐ brachial pulse

‐ ulnar nerve ‐ radial nerve ‐ median nerve

i) Wrist and Hand:

‐ radial styloid and dorsal tubercle ‐ ulnar styloid

‐ scaphoid – tubercle, anatomical snuff box ‐ trapezium ‐ pisiform

‐ lunate ‐ triquetrum

‐ trapezoid ‐ capitate ‐ hamate

‐ hook of hamate ‐ metacarpal heads and bases ‐ phalanges

‐ inferior radio-ulnar joint ‐ tendons of wrist and hand ‐ thenar and hypothenar muscles

‐ palmar aponeurosis ‐ flexor retinaculum ‐ triangular fibrocartilage complex (TFCC)

‐ radial artery/ulnar artery ‐ radial nerve/ulnar nerve ‐ scapholunate and lunotriquetral joints (interosseous ligaments)

‐ tunnel of Guyon ‐ 1st MCP joint - ulnar collateral ligament

5. Subjective Assessment:

‐ mandatory questions for all musculoskeletal disorders (screening for red flags) ‐ specific additional questions pertaining to each joint and/or region


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‐ interpretation on completion of subjective assessment (refer to clinical reasoning reflection form – appendix)

6. Objective Assessment: (Theory)

Testing and interpretation of results to determine differential diagnosis: Selective tissue tension differentiation (1 hour)

‐ inert vs. contractile tissue lesions ‐ capsular vs. noncapsular patterns of restriction

‐ end feels; normal and abnormal ‐ interpretation of resisted tests

7. Upper and Lower Quadrant Scan: (Practical)

a) Observation - architectural design of postural status in three planes in both standing and sitting

b) Gait observation c) Active range of motion (AROM) spine and lower extremities d) Passive range of motion (PROM) – overpressure on AROM e) Generalized congenital hypermobility assessment (Beighton Scale) f) Neurological scan – theory and practical

i) Sensory testing (dermatomes) ii) Key muscle testing (myotomes) iii) Reflexes (deep tendon) iv) Additional long tract tests:

‐ plantar reflex (Babinski)

‐ ankle & wrist clonus ‐ Oppenheimer ‐ Hoffman

v) Cranial nerve testing g) Neurodynamic tests: theory, indications, contraindications and practical

Upper quadrant: i) neck flexion test ii) upper limb neurodynamic test (ULNT)

Lower quadrant: i) prone knee bend ii) straight leg raise test

‐ bowstring

‐ neck flexion ‐ dorsiflexion of the foot (Lasegue's)

iii) slump test i) Arterial patency tests

‐ peripheral pulses ‐ cervical arterial dysfunction screening (refer to IFOMPT CAD Framework)

h) Resisted isometric tests ‐ submaximal first to screen for serious pathology or contractile lesion

‐ maximal break test for strength assessment (Grade 0 to 5) ‐ repeated contraction for endurance

i) Articular screening - general traction and compression cervical, thoracic and lumbar spine


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- posterior-anterior pressure spinous processes (central PAs) - Farfan’s torsion (lumbar spine) - pelvis distraction and compression through the ASISs

j) Spine palpation

‐ segmental and multisegmental muscle tone 8. Upper and Lower Quadrant Detailed Biomechanical Assessment: (Practical)

For all vertebral and peripheral joint complexes unless otherwise indicated a) Passive single plane stability tests:

*Note: The Orthopaedic Division recognizes that stability testing assesses multiple structures i.e. there will be both primary and secondary stabilizers to a single plane of motion.

i) Lumbar Spine:

‐ anterior and posterior translation ‐ torsion (segmental and regional – Farfan’s torsion test)

ii) Pelvis: a. Sacroiliac Joint:

‐ transverse anterior distraction: posterior compression (pain provocation test)

‐ transverse posterior distraction: anterior compression (pain provocation test) ‐ superior and inferior translation ‐ anterior and posterior translation

b. Pubic symphysis: ‐ superior and inferior translation

iii) Hip: ‐ torque test

iv) Knee - Tibiofemoral: ‐ valgus at 0°, 30°, 90° knee flexion

‐ varus at 0° and 30° knee flexion ‐ anterior (ACL)

‐ anterior drawer test

‐ Lachman’s Test ‐ posterior (PCL)

‐ posterior sag test ‐ posterior drawer test

v) Inferior Tibio-fibular Joint:

‐ anterior and posterior mobility vi) Talocrural Joint:

‐ anterior drawer test ‐ posterior drawer test

‐ varus and valgus in varying degrees of DF/PF vii) Craniovertebral Joints - occipitoatlantal joints (OA) and atlantoaxial joints (AA):

‐ Sharp-Purser test ‐ anterior translation AA ‐ lateral translation AA

‐ rotary OA/AA complex (side flexion testing for alar ligament) viii) Cervical Spine:

‐ anterior and posterior translation ‐ lateral translation

ix) Thoracic Spine:


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‐ anterior and posterior translation

‐ lateral translation ‐ torsion

x) Glenohumeral:

‐ anterior ‐ inferior: sulcus sign test

x) Elbow: (radiohumeral/ulnohumeral) ‐ valgus at 0°, 30°, 90° elbow flexion

‐ varus at 0° and 30° elbow flexion xi) Wrist and Hand:

‐ collateral ligaments of the radiocarpal joint

b) Passive mobility tests of the spine:

i) Uniplanar passive physiological intervertebral movements (PPIVMs):

‐ bilateral flexion and extension ‐ side flexion

‐ rotation ii) Passive accessory intervertebral movements (PAIVMs) - assessed prone in neutral

spine: ‐ posterior/anterior pressure (PA) on spinous process (included in Scan)

‐ unilateral posterior anterior pressure on transverse process

9. Pain provocation Tests

i) traction and compression all UQ and LQ joints - for the spine this is specific traction and compression (general traction and

compression are included in the scan)

10. Muscle Strength and Length Tests

Graded resisted manual muscle testing for all upper and lower quadrant muscles

11. Special tests: i) Knee:

a. Effusion tests:

‐ patellar tap ‐ milking/swipe

‐ Meniscus tests:

‐ McMurray’s ‐ Thessaly

ii) Shoulder:

‐ Scapulohumeral rhythm ‐ Apprehension test

‐ Impingement tests: Hawkins Kennedy, Neer’s impingment, Posterior Internal impingement test

12. Analyze the Total Assessment Data:

Demonstrate the ability to use evidence informed clinical reasoning to analyze the total assessment data and identify the following: i) patient’s provisional differential diagnosis and treatment plan


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ii) the presence of adverse effects/complications of assessment or of non-mechanical pain indicating further medical assessment is required

13. Conditions:

At this level the participant, through analyzing the assessment data, should be able to identify the following conditions, which should therefore be discussed, be reviewed in the manual and/or given in a case history format: a) General:

i) neurological compromise: -central nervous system -peripheral nervous system -autonomic nervous system

ii) osteoarthritis including post-traumatic arthritis – basics only iii) systemic and connective tissue disorders / conditions iv) tumors v) viscerogenic pain

b) Spinal:

i) cervical / thoracic / lumbar / sacral root radiculopathy ii) cervical artery dysfunction (basic information - i.e. ischemic and non-ischemic signs and

symptoms, screening tests, history) iii) altered mobility of the spine (introduction to concepts and differentiating articular, motor

control and motor performance impairments) iv) cauda equina syndrome v) spinal cord compression vi) lumbar disc herniation vii) lumbar spinal stenosis

c) Peripheral:

i) inert tissue lesions - capsular patterns, ligament injuries, acute bursitis, painful arc syndromes

ii) contractile tissue lesions – acute muscle strain 11. Treatment:

a) Basic Acute Treatment Principles: i) rest ii) thermo-, hydro-, electro-physical agents iii) exercise iv) ergonomic analysis and appropriate modification vi) discussion of medical emergency / medical urgency care procedures

b) Introduction to manual therapy: i) Grades and Choice of Grades ii) spine:

‐ graded intervertebral PAs central and unilateral

‐ graded PPIVMs flexion/extension, combined rotation/side flexion in neutral

c) Deep Transverse Frictions: (Theory) Indications/contraindications during the three stages of healing: i) substrate


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ii) fibroblastic iii) remodeling

d) Deep Transverse Frictions: (Practical)

‐ positioning of the structure ‐ depth, duration, sweep

‐ therapist biomechanics

e) Manual and Mechanical Traction (cervical/thoracic/lumbar): i) indications ii) contraindications iii) method:

‐ position ‐ static vs. intermittent ‐ progression - time vs. poundage

f) Basic Spinal Care:

i) resting positions: pillows, beds, etc. ii) evidence informed working positions: static and dynamic iii) lifting techniques: basic mechanics of lifting

g) Orthoses, Collars and Supports:

i) collars: ‐ indications for hard/soft collars

‐ patient education regarding the use of the collar ii) lumbar supports/sacroiliac belts:

‐ indications ‐ patient education regarding the use of the support

iii) peripheral orthosis:

‐ indications

‐ patient education regarding the use of the orthosis

12. Recording Assessment Data Use of body charts and articular diagrams for charting – demonstrate with handouts

13. Physiotherapy Clinical Relevance of Medical Testing/Treatment Including: * May be included as a reading assignment. Consider relevance to conditions / cases as part of clinical reasoning exercises

14. Legal Aspects of Musculoskeletal Physiotherapy:

*May be included as a reading assignment

‐ informed consent and consent to treat ‐ record keeping

‐ the rights and obligations of third parties and patient information release ‐ sexual harassment ‐ malpractice

‐ product endorsement ‐ medical legal reports ‐ giving expert witness to testimony


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‐ direct access

‐ federal and provincial laws on manipulative therapy

15. Overview of Other Disciplines Involved with Musculoskeletal Treatment:

‐ discussion regarding collaborative care

‐ refer to theory resource

16. Therapeutic Alliance: *A brief familiarization of the following may be included as a reading assignment:

‐ basic manual therapy terminology

‐ adult education ‐ communication methods and pitfalls especially with regards to:

◊ therapist-patient communication ◊ therapist-physician communication ◊ therapist-layman communication ◊ medical legal communication

17. History of Manual Therapy: *A brief familiarization of the following - may be included as a reading assignment

‐ leading figures in manual therapy

‐ various philosophies and approaches to manual therapy ‐ other professions engaged in manual therapy ‐ national and international manual therapy organizations i.e. International Federation of

Manipulative Physical Therapists (IFOMPT), Canadian Academy of Manipulative Physical Therapists (CAMPT)

‐ current professional issues relevant to the practice of orthopaedic manual therapy

18. Scientific Inquiry:

To enhance the knowledge of the theory of manual therapy practice and encourage critical review of its scientific merit there must be an introduction to the following basic principles. In depth consideration will be addressed in the Critical Appraisal course :

‐ epidemiology (populations, samples, allocation of subjects) ‐ the terms validity/ reliability/ variables/ pre and post test probability/sensitivity/specificity/

positive and negative likelihood ratios) ‐ research methodology and design (measurement; experimental, quasi- experimental

and non-experimental) ‐ biomedical statistics (descriptive and inferential; parametric and non-parametric)

‐ ethics in research ‐ methods of literature searches ‐ scientific inquiry in clinical practice and with writing / reading scientific papers

CPA Diploma of Advanced Integrated Musculoskeletal Physiotherapy Program: Policies and Procedures– Education and Examination Standards Document: Version: Jan 2020 Level II Lower Quadrant Curriculum

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LEVEL 2 – LOWER QUADRANT COURSE (12 days) Total Hours: 85 hours (83 instruction / 2.0 examination)

A. PURPOSE: Course participants will learn current theories of biomechanics and the application of these biomechanics in the neuromusculoskeletal physiotherapy assessment and treatment of the lower quadrant (lumbar spine, pelvic girdle and lower extremity peripheral joints) utilizing evidence informed clinical reasoning consistent with the ICF and a biopsychosocial model. This course builds on the clinical skills and theoretical knowledge gained at Level 1.

B. OBJECTIVES:

At the completion of this course, the student will demonstrate competency in: 1. Use of biomechanical concepts and terminology as they apply to osteokinematic and

arthrokinematic motion.

2. Introductory concepts of neuromeningeal mechanosensitivity assessment and treatment in the lower quadrant

3. Applying a clinical reasoning and biopsychosocial approach to assessment, and identification of

the presentation, clinical implications, and management of pathology in the lower quadrant 4. Integrating into clinical reasoning processes current knowledge regarding the origin and

complications of benign mechanical and degenerative disorders of the lower quadrant. 5. Basic understanding of the influence of distal and proximal tissues (static and dynamic) on

normal and pathological musculoskeletal states (regional interdependence), indications and contraindications to assessment and treatment, and indications for medical or surgical interventions.

6. Applying theoretical principles to practical application of soft tissue, neuromeningeal, and

articular assessment and treatment procedures in the lower quadrant with attention to the correct grade, direction, and duration of the manual therapy technique, and expected mechanical and physiological effects.

7. Integrating the principles and practical application of safe and effective high velocity manipulative

procedures to the lumbar spine and specific lower quadrant peripheral joints. 8. Performance of standardized neuromusculoskeletal subjective and objective physiotherapy

assessment and treatment including analyzing and modifying dynamic and static postures, and developing home exercise programs.

9. Applying evidence informed practice for analyzing assessment findings, including using

clinical prediction rules, outcome measures, and the ICF framework to assist in establishing a rationale for pathology and treatment.


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C. TOPICAL OUTLINE: 1. Clinical Reasoning:

Review of Level 1 content

2. Anatomy:

a) Detailed osteology, arthrology, myology, neurology, vascularization, function, dynamic and static stability of the lumbar vertebral joints (including discs), pelvic region and lower quadrant peripheral joints (including type and classification of joint receptors)

b) Inter and intra regional differences of the lumbar zygapophyseal joints and intervertebral discs

c) Form and force closure using the pelvic region as an example d) Articular cartilage morphology/physiology including degeneration, and synovial joint

lubrication (rheology)

3. Congenital Anomalies:

‐ asymmetry of facets (tropism), ‐ transitional vertebra (lumbarization, sacralization) ‐ trapezoidal L5

‐ asymmetry of the sacrum ‐ block vertebrae

‐ hemi-vertebrae ‐ congenital stenosis ‐ spina bifida

‐ leg length discrepancy ‐ knee anomalies i.e. patella alta / baja ‐ hip anomalies in angulation and version

‐ structural deformities of the foot and ankle i.e. pes planus, pes cavus

4. Neurophysiology and Neurodynamics: In addition to reviewing pain mechanisms and segmental facilitation introduced in Level 1 the following material should be introduced at Level 2:

‐ Normal anatomy, basic handling and principles of neuromechanical sensitivity and testing, normal/abnormal responses, indications for biasing specific nerves, and basic treatment - sliders and tensioners

5. Surface Anatomy:

Review of palpation of articular and soft tissue structures introduced in Level 1. In addition the following should be introduced at Level 2: a) Ankle Ligaments:

‐ anterior / posterior inferior tib-fib ligaments ‐ cervical

‐ lateral and medial talocalcaneal ‐ dorsal talonavicular

‐ plantar calcaneonavicular ‐ long and short plantar ligaments ‐ dorsal calcaneocuboid

‐ plantar fascia 6. Biomechanics of Joints:

Include the definition and clinical significance of the following for the lower quadrant:


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‐ osteokinematics and arthrokinematics ‐ mechanical axis, instantaneous axis of rotation ‐ movement of bones: spins and swings

‐ movement of joints: rolls, spins and slides, close packing and rest position of joints, coupling motions

‐ congruent, adjunct, conjunct rotation of bones ‐ classification of joints: simple, compound, complex ‐ classification of joint surface shape: modified and unmodified ovoid and modified and

unmodified sellar joints, convex, concave ‐ range of motion and degrees of freedom of movement for the lower quadrant including the

lumbar spine (visual, manual, goniometric, inclinometer) ‐ normal and abnormal motion states (normal, hypomobile, hypermobile, unstable)

‐ normal and abnormal loading of the spine (especially with reference to the lumbar spine and pelvis i.e. pelvic form and force closure)

‐ normal biomechanics of lifting, standing, sitting, squatting ‐ efficient and inefficient posture

‐ habitual movements ‐ introduction to the functional and dysfunctional biomechanical interrelationship of adjacent

joint and surrounding tissue

‐ normal and pathological mechanical deformation of neural and vascular structures of the lower quadrant including the lumbar spine and pelvis during spinal and peripheral movement

‐ theoretical and practical considerations of biomechanical assessment and treatment


Review subjective assessment introduced in Level 1 ‐ mandatory questions for all musculoskeletal disorders (screening for red flags)

‐ specific additional questions pertaining to each joint and/or region ‐ interpretation and hypothesis development on completion of subjective assessment (refer to

clinical reasoning reflection form adapted from Jones & Rivett 2003)

8. Lower Quadrant Scan:

Review from Level 1

9. Detailed Biomechanical Assessment:

Detailed neuromusculoskeletal physiotherapy objective assessment of the lower quadrant including the lumbar spine and pelvis. a) Active physiological mobility tests (AROM): (3 hours)

i) Lumbar spine: a. uniplanar active movements – flexion, extension, side flexion, and rotation b. combined active movements – quadrants, and H and I patterns

ii) Lower quadrant peripheral joints: a. uniplanar active movements b. combined active movements – functional movements

b) Passive mobility tests: (8 hours)

i) Passive physiological mobility tests – uniplanar and combined a. Lumbar spine: passive physiological intervertebral movements (PPIVMs) assessed

in side lying:


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n.b. Always rotate the torso away from therapist (i.e. spine rotation is opposite to side patient is lying on) i. uniplanar movements:

‐ bilateral flexion/extension ‐ side flexion (optional) ‐ rotation (optional)

ii. combined movements: ‐ ipsilateral coupling of side flexion and rotation (optional)

‐ contralateral coupling of side flexion and rotation (optional) ‐ ipsilateral coupling of sideflexion and rotation in extension ‐ contralateral coupling of sideflexion and rotation in flexion

b. Lower quadrant peripheral joints: passive range of motion (PROM):

i. uniplanar movements ii. combined movements (quadrants)

ii) Passive accessory mobility tests (joint play/glides):

a. Lumbar spine: passive accessory intervertebral movements (PAIVMs) assessed in prone with neutral spine: ‐ unilateral anterosuperior/inferoposterior glides on transverse process

‐ posterior/anterior pressure (PA) on spinous process

b. Lower quadrant peripheral joints: passive accessory glides assessed in resting position

c) Joint stability, pain provocation tests: (passive and dynamic) (6 hours)

*Note: The Orthopaedic Division recognizes that stability testing assesses multiple structures i.e. there will be both primary and secondary stabilizers to a single plane of motion.

Review of joint stability and provocation tests introduced in Level 1. In addition to Level 1 lower content, the following should be introduced at Level 2:

i) Lumbar Spine - Prone instability test (PIT) - Passive lumbar extension test (PLE) - Posterior shear test

ii) Pelvis: a. Sacroiliac Joint:

‐ active straight leg raise

‐ load transfer test ‐ pain provocation tests: anterior and posterior SI Joint gapping, P4, Patrick’s

(FABER) test, sacral thrust, palpation of long dorsal and sacrotuberous ligaments, Gaenslen’s

ii) Hip - Long roll - Long axis femoral distraction - Apprehension test

iii) Knee Joint: a. Tibiofemoral Joint:

- anterolateral: pivot shift - posterior (PCL): quadriceps active test


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b. Patellofemoral Joint: ‐ apprehension test

‐ Medial translation c. Superior Tibio-fibular Joint

‐ compression ‐ anterior and posterior translation

iii) Foot and Ankle Joints: a. Talocrural

Anterior and posterior drawer Varus/valgus

b. Inferior tibio-fibular Joint:

‐ squeeze test ‐ dorsiflexion external rotation test (Kleiger)

‐ weight bearing dorsiflexion splay with measurement c. Subtalar Joint:

‐ distraction/compression ‐ varus stability ‐ valgus stability

d. Midfoot and Forefoot Joints: ‐ distraction and compression all mid and forefoot joints

‐ dorsal and plantar translation all mid and forefoot joints ‐ specialized testing for:

◊ spring ligament ◊ dorsal talonavicular ligament ◊ dorsal calcaneocuboid ligament ◊ long and short plantar ligaments

‐ varus and valgus for MTP/IP collateral ligaments

d) Neurobiomechanical tests: (4.5 hours) In addition to reviewing neurodynamic test theory content from Level 1 introduce individual nerve biasing for the following nerves

i) Femoral nerve - prone knee bend, slump knee bend

‐ Saphenous nerve ii) Sciatic nerve - slump, SLR

‐ Tibial nerve

‐ Common peroneal nerve ‐ Superficial and Deep peroneal nerve ‐ Sural nerve

iii) Obturator nerve iv) Lateral femoral cutaneous nerve

e) Special tests: (3 hours)

i) Bursa testing all regions ii) Leg length testing iii) Hip:

‐ FABER test (Patrick’s test) ‐ quadrant tests

iv) Knee: - McMurray’s test

‐ Thessaly test


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- joint line palpation - Q-angle - plica test - Wilson’s test - McConnell’s critical angle - Noble’s test

v) Foot and Ankle:

- Homan’s test - talar swing test - Thompson test

10. Analyze the Total Assessment Data (7 hours)

Refer to Jones and Rivett 2003 Clinical Reasoning for Manual Therapists a) General:

Demonstrate the ability to use clinical reasoning and evidence informed principles including:

‐ the International Classification of Functioning Disability and Health (ICF) model ‐ generic, condition specific, and patient specific outcome measures ‐ diagnostic test accuracy and reliability

‐ prognostic indicators to analyze the total assessment data and identify the following:

‐ patient’s diagnosis ‐ indications and contraindications to musculoskeletal physiotherapy assessment and

treatment ‐ appropriate referral and communication to other members of the health care team in

the presence of adverse effects/complications of assessment or indication of non-mechanical pain requiring further medical assessment.

b) Specific: ‐ subjective assessment

◊ determine a hypothesis of pathology ◊ determine co-existing factors or pre-existing history of trauma ◊ determine the components of the physical assessment to assess

‐ palpation of articular and soft tissue structures ‐ active uniplanar and combined physiological mobility tests

‐ passive uniplanar and combined physiological and accessory mobility tests ‐ joint stability and ligament stress tests (passive and dynamic) ‐ neuromeningeal mobility and sensitivity tests

‐ neurological conduction testing ‐ relevant special tests for the region

For the above section should be able to describe the following:

‐ the relationship of pain, resistance, and spasm ‐ rationale for motion and / or strength limitation

‐ end feels and their relationships to available motion and quality of motion ‐ consistency with the subjective assessment ‐ confirmation or negation of the generated hypothesis of pathology

‐ determination of co-existing factors ‐ additional components of the physical examination that need to be done with expected

outcomes


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11. Conditions:

The emphasis of this course is lower quadrant musculo-skeletal function and dysfunction and the following conditions should be covered via lectures, course manual and / or in case histories: (relate functional findings to underlying pathology) a) General:

‐ capsular and non-capsular lesions ‐ connective tissue injuries i.e. ligament injuries ‐ bursitis

‐ peripheral articular dysfunction including fixations, instabilities ‐ peripheral arthritides including ankylosing spondylitis ‐ Paget’s disease

‐ adverse neuromeningeal tension ‐ non-mechanical pain i.e. viscero-genic causes of pain

‐ immobilization stiffness ‐ specific age and or sex related pathologies ‐ fractures

‐ impingements (general information) ‐ peripheral joint loose bodies

b) Spinal:

‐ disc pathology (Age related changes, traumatic lesions) ‐ central and lateral spinal stenosis/intermittent claudication

‐ spondylosis, spondylolysis and spondylolisthesis ‐ segmental articular dysfunction: articular hypomobilities, hypermobilities, instabilities,

fixations c) Pelvis:

‐ sacroiliitis, AKS, Reiter’s ‐ SI joint hypomobility (fixations)

‐ SI joint hypermobility d) Hip:

‐ congenital hip dislocation/dysplasia ‐ Legg-Calve-Perthes ‐ slipped capital epiphysis

‐ hip osteoarthritis ‐ tendinopathy

e) Knee:

‐ cysts, loose bodies and meniscus tears ‐ ligament sprain/instability

‐ knee osteoarthritis ‐ osteochondritis dissecans ‐ patellar instability/dislocation

‐ PFPS as a local condition ‐ tendinopathy

‐ Osgood Schlatter, Sinding-Larsen-Johansson f) Ankle and Foot:

‐ Achilles tendinopathy ‐ Compartment syndrome ‐ lateral ankle sprains

‐ osteochondritis dessicans ‐ local plantar fasciitis


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‐ osteoarthritis 1st MTP ‐ Hallux Valgus ‐ Morton’s neuroma

12. Treatment:

a) General: (3 hours) Demonstrate the ability to use clinical reasoning and evidence informed principles to analyze the total examination data including:

‐ the International Classification of Functioning Disability and Health (ICF) model ‐ generic, condition specific, and patient specific outcome measures ‐ principles of wound repair and the role of physiotherapy in this process

‐ principles of treatment progression and reasons for discontinuation ‐ prognostic indicators

‐ level of evidence of treatment technique in order to determine:

‐ an initial treatment regime or alternate action ‐ treatment effectiveness, and when to progress or modify treatment ‐ appropriate referral and communication to other members of the health care team in

the presence of adverse effects/complications of treatment ‐ a planned prevention program

b) Joint Mobilization: (12 hours)

*Mobilization is defined as “The skillful active, active assisted and/or passive accessory movement (compression/distraction/glides) of a joint complex within its physiological range of motion.” i) Types of mobilization:

‐ glides ‐ distraction

ii) Selection of technique - grade and duration as related to the aims of treatment and stages of healing

iii) Application of technique in all ranges of motion of the joint (relate the indications to the appropriate range of motion for treatment)

iv) Indications and contraindications for the application of mobilization procedures to the lower quadrant including lumbar spine and pelvis

v) Basic introduction to the principles of the following mobilization approaches:

‐ Maitland ‐ McKenzie ‐ Kaltenborn (Norwegian approach)

‐ Mulligan (NAGS and SNAGS) ‐ Muscle assisted techniques - Muscle Energy Technique (MET), proprioceptive

neuromuscular facilitation (PNF) vi) Effects of mobilization:

a. Joint rheology - effects of mobilization and immobilization on the morphology and physiology of articular cartilage and the degenerative process

b. Joint neurophysiology - effects of mobilization on joint receptors c. Pain - effect of mobilization on:

- mechanical pain - chemical/inflammatory pain - spinal modulation of pain (gate control)


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- central modulation of pain d. Effects of local mobilization on the normal and abnormal motion states of distal and

proximal tissues

c) Manipulation: (2 hours) *Manipulation is defined as: “A skillful passive high velocity, low amplitude thrust movement of a joint (peripheral or spinal) beyond its physiological limit of motion but inside the limit of its anatomical integrity with the purpose of restoring motion and function.”

i) Manipulation theory - discuss in detail the theories of joint fixation of the lower quadrant spinal, pelvic, and peripheral joints

ii) Types of manipulation: a. articular glide manipulations

‐ direct thrust along the line of the articular glide ‐ parallel to the articular surface ‐ physiological movement can be used to produce the glide

b. distraction manipulations ‐ gapping techniques

‐ perpendicular to the articular surface iii) Selection of technique iv) Application of technique v) Indications contraindications and techniques for the application of the following

manipulations to the lower quadrant joints:

‐ first metatarsophalangeal joint distraction ‐ subtalar joint eversion - dynamic

‐ subtalar joint inversion - dynamic ‐ talocrural joint distraction ‐ talocrural joint posterior thrust (glide)

‐ talocrural joint loose body ‐ knee joint loose body ‐ hip joint loose body

‐ sacro-iliac joint inferior thrust (prone/supine) ‐ lumbar spine unilateral oblique distraction (gap)

vi) Effects of manipulation on:

‐ pain

‐ neurophysiology ‐ muscular ‐ articular

‐ collagen tissue i.e. adhesions ‐ the normal and abnormal motion states of distal and proximal tissues

d) Neuromeningeal mobilization: (2 hours)

i) Neuromeningeal mobilization treatment theory ii) Selection of treatment technique iii) Application of technique (basic sliders with one or two basic home exercises) iv) Indications and contraindications v) Effect of neuromobilization on:

i) Pain: ◊ mechanical ◊ chemical/inflammatory


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◊ spinal modulation of pain (gate control) ◊ central modulation of pain

ii) Tissue mobility

e) Case studies to demonstrate principles of clinical reasoning in the manual and manipulative physiotherapy treatment approach to abnormal motion states (hypomobilities, hypermobilities, instabilities): (4 hours) i) joint mobilization/manipulation ii) Basic neuromeningeal mobilization iii) Basic exercise therapy

‐ position of optimal postural balance for static and dynamic postures ‐ home program including dynamic postural integration into activities of daily living

muscle imbalance evidence informed principles of trunk muscle recruitment-segmental and regional

iv) rationale and indications of adjunct non-manual therapy modalities (thermo-, hydro-, electrophysical agents, taping, orthosis)

13. Recording Data: (0.5 hour)

* May be included as a reading assignment Discussion of various standardized forms

14. Physiotherapy Clinical Relevance of Medical Testing/Treatment for the Lower Quadrant:

(1 hour) * May be included as a reading assignment

See Level 1 list in this document

15. Scientific Inquiry: (2 hours)

* May be included as a reading assignment See Level 1 content in this document

16. Current Issues in Physiotherapy: (0.5 hour)

‐ current professional issues relevant to the practice of musculoskeletal physiotherapy ‐ jurisprudence (medical-legal issues)

Evaluation Methods

Continuous in-course skill evaluation / Interactive case history / 60 MCQ examination

CPA Diploma of Advanced Integrated Musculoskeletal Physiotherapy Program: Policies and Procedures– Education and Examination Standards Document: Version: Jan 2020 Level II Upper Quadrant Curriculum

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LEVEL 2 – UPPER QUADRANT COURSE (12 days) Total Hours: 85 hours

A. PURPOSE: Course participants will learn current theoretical concepts related to the biomedical, clinical and behavioural sciences of neuromusculoskeletal physiotherapy assessment and treatment of the upper quadrant utilizing evidence informed clinical reasoning consistent with the ICF and a biopsychosocial model. This course builds on the clinical skills and theoretical knowledge gained at Level 1.

B. OBJECTIVES:

At the completion of this course, the student will demonstrate competency in: 1. Use of biomechanical concepts and terminology as they apply to osteokinematic and

arthrokinematic motion.

2. Introductory concepts of neural mechanosensitivity assessment and treatment in the upper quadrant

3. Applying a clinical reasoning and biopsychosocial approach to assessment, and identification of the presentation, clinical implications, and management of pathology in the upper quadrant.

4. Integrating into clinical reasoning processes current knowledge on the origin and complications of benign mechanical and degenerative disorders of the upper quadrant.

5. Basic understanding of - the influence of distal and proximal tissues (static and dynamic) on normal and

pathological neuromusculoskeletal states (regional interdependence) - indications and contraindications to assessment and treatment - indications for medical or surgical interventions.

6. Applying theoretical principles to practical skill application of soft tissue, neural, and articular assessment and treatment procedures in the upper quadrant with attention to the correct grade, direction, and duration of manual therapy technique, and expected mechanical and neurophysiological effects.

7. Integrating the principles and practical application of safe and effective high velocity manipulative procedures to the thoracic spine and specific upper quadrant peripheral joints.

8. Applying evidence informed practice for analyzing assessment findings, including an understanding of the diagnostic accuracy and clinical utility of physical examination tests; clinical application of validated clinical prediction rules; use of outcome measures and an understanding of the psychometric properties and the integration of the ICF framework to assist in establishing a biopsychosocial approach to management.

C. TOPICAL OUTLINE:


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1. Clinical Reasoning:

Review of Level 1 content

2. Anatomy: (11.5 hours)

a) detailed osteology, arthrology, myology, neurology, vascularization, function, mechanical and functional stability of the cervical and thoracic vertebral joints (including discs), costal joints and upper quadrant peripheral joints (including type and classification of joint receptors)

b) inter and intra regional differences in cervical and thoracic zygapophyseal joints and intervertebral discs

c) neurology of the cranial nerves and associated autonomic nervous system d) general organization, structure and function of the components of the visual, vestibular and

auditory system e) anatomy of the blood supply of the peripheral nervous system and central nervous system

with emphasis on brain, spinal cord, meninges, and nerve roots, including the vertebral and carotid artery.

3. Congenital Anomalies: (1 hour)

a) Neural anomalies: eg spinal dysraphism/spina bifida/tethered cord syndrome/neural tube defects, chiari malformations

b) Soft tissue: eg Marfan Syndrome, Ehlers Danlos, etc c) bony: spinal and upper extremity anomalies: eg Klippel Feil, osteogenesis imperfecta,

congenital bony or vertebral fusion, scoliosis etc 3. Neurophysiology and Neurodynamics:

In addition to reviewing pain mechanisms and segmental facilitation introduced in Level 1 the following material should be introduced: ‐ Normal anatomy, basic handling and principles of neuromechanical sensitivity and testing,

normal/abnormal responses, indications for biasing specific nerves, and basic treatment - sliders and tensioners

4. Biomechanics of Joints (4 hours) Include the definition and clinical significance of the following for the upper quadrant:

‐ osteokinematics and arthrokinematics ‐ mechanical axis, instantaneous axis of rotation

‐ movement of bones: spins and swings ‐ movement of joints: rolls, spins and slides, close packing and rest position of joints, coupling

motions

‐ congruent, adjunct, conjunct rotation of bones

‐ classification of joints: simple, compound, complex ‐ classification of joint surface shape: modified and unmodified ovoid and modified and

unmodified sellar joints, convex, concave

‐ range of motion and degrees of freedom of movement for the upper quadrant spine and measurement methods (visual, manual, goniometric, inclinometer measurements)

‐ normal biomechanical classification of the upper quadrant ‐ normal and abnormal motion states (normal, hypomobile, hypermobile, unstable)

‐ normal upper quadrant biomechanics of lifting, standing, sitting ‐ efficient and inefficient posture ‐ habitual movements


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‐ introduction to the biomechanical interrelationship of adjacent joint and surrounding tissue ‐ mechanical deformation of neural and vascular structures of the upper quadrant during

spinal and peripheral movement

‐ theoretical aspects and practical considerations of biomechanical treatment

5. Surface Anatomy: (4.5 hours)

Review of palpation of articular and soft tissue structures introduced in Level 1 - the following additional content should be introduced at Level 2: a) Wrist and Hand

‐ Carpal and intercarpal joints, CMC joint of the thumb, MCPs, IPs 6. Subjective Assessment:

Review subjective assessment introduced in Level 1:

‐ mandatory questions for all musculoskeletal disorders (screening for red flags) ‐ specific additional questions pertaining to each joint or region

‐ interpretation and hypothesis development on completion of subjective assessment – see Clinical Reasoning Reflection Form

7. Upper Quadrant Scan:

Review Upper Quadrant Scan introduced in Level 1

8. Detailed Biomechanical Assessment: Detailed musculoskeletal objective assessment of the upper quadrant with review of Level 1 content and addition of the following: a) Active Range of Motion (AROM) (2 hours)

i) Cervical and Thoracic Spine:

‐ uniplanar active movements – flexion, extension, side flexion, and rotation ‐ combined active movements – quadrants

ii) Ribs

‐ Breathing iii) Upper quadrant peripheral joints:

‐ uniplanar active range of movements

‐ combined active movements - functional movements

b) Passive mobility tests (8.5 hours) i) Passive physiological mobility tests/PROM:

a. Cervical Spine:

Uniplanar PPIVMs :

‐ uniplanar flexion and extension ‐ rotation / side flexion

Combined PPIVMs:

‐ Ipsilateral coupling of side flexion and rotation in flexion ‐ Ipsilateral coupling of side flexion and rotation in extension

b. Thoracic Spine:

Uniplanar PPIVMs : ‐ uniplanar flexion and extension


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‐ side flexion ‐ rotation

Combined PPIVMs:

‐ Ipsilateral coupling of side flexion and rotation ‐ Contralateral coupling of side flexion and rotation

‐ Ipsilateral coupling of side flexion and rotation in flexion and in extension ‐ Contralateral coupling of side flexion and rotation in flexion and in

extension

c. Upper quadrant peripheral joints passive range of motion (PROM): i. combined movements (quadrants)

iii) Passive accessory mobility tests (joint play/glides):

a. Cervical and Thoracic Spine passive accessory intervertebral movements (PAIVMs) assessed in neutral and at end of available range (at restriction)

‐ unilateral anterosuperior superoanterior and inferoposterior glides on transverse process

‐ central posterior/anterior glides directed cranially or caudally on the spinous processes

b. Upper quadrant peripheral joints: passive accessory glides assessed in neutral and and into restriction

c) Single plane passive stability tests: (passive and dynamic) (8 hours) *Note: The Orthopaedic Division recognizes that stability testing assesses multiple structures i.e. there will be both primary and secondary stabilizers to a single plane of motion.

Review of joint stability tests introduced in Level 1. In addition to Level 1 upper content, the following should be introduced at Level 2: i) Thorax:

a. Thoracic Spine:

‐ lateral translation (entire thoracic vertebra rib complex/ring) b. Costotransverse Joints (vertebrosternal/vertebrochondral region):

‐ distraction ‐ superior/inferior translation

c. Costochondral and Sternochondral Joints: ‐ anterior and posterior translation

‐ superior and inferior translation

ii) Shoulder: a. Glenohumeral Joint:

‐ Anterior/inferior translation in ER at varying degrees of abduction ‐ posterior translation in IR and adduction at varying degrees of flexion

‐ 0° anterior and posterior (load and shift), ‐ inferior (sulcus)

b. Acromioclavicular Joint: ‐ Paxino’s sign

‐ Obervation/palpation ‐ horizontal adduction with overpressure ‐ anterior and posterior translation

c. Sternoclavicular Joint:


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‐ anterior and posterior translation

iii) Elbow Joint: Review of varus/valgus stability testing

Proximal Radioulnar Joint:

‐ distraction and compression

‐ anterior translation radius in full supination ‐ posterior translation radius in full pronation

iv) Wrist and Hand:

‐ Compression of triangular fibrocartilage complex (TFCC) ‐ anterior, posterior, radial, and ulnar translation radiocarpal and midcarpal joints

‐ dorsal and palmar translation individual proximal row carpals on distal radius and ulna and each intercarpal joint (ballottement)

‐ 1-5 MCP and IP joint valgus stress at 0° and 30° ‐ 1-5 MCP and IP joint varus stress at 0° and 30° ‐ 1st CMC varus/valgus and palmar/dorsal stress tests

a. Distal Radioulnar Joint

‐ compression ‐ anterior translation ulna in full supination

‐ posterior translation ulna in full pronation

d) Neurodynamic tests including adjunct testing (2 hours) Review neuromeningeal theory, indications, contraindications content from Level 1 ‐ Median nerve - upper limb neurodynamic test 1 and 2a

‐ Redial nerve - upper limb neurodynamic test 2b ‐ Ulnar nerve - upper limb neurodynamic test 3

e) Cranial nerve tests (1 hour) – review from Level 1

f) Dizziness differentiation tests – subjective and physical examination tests for vascular

pathologies in the cervical spine refer to the IFOMPT screening document (1 hour)

g) Special tests: (3 hours) i) Shoulder:

‐ Speed’s test, Yergason’s test ‐ drop arm test

‐ empty can test ‐ impingement tests (Hawkins, Neer)

ii) Wrist and Hand:

‐ Finkelstein test ‐ Allen test ‐ Phalen’s test, Tinel’s sign

‐ scaphoid tests (fracture, Watson’s scaphoid shift test) ‐ TFCC grind test


38

9. Analyze the Total Assessment Data (5 hours) a) General:

Demonstrate the ability to use clinical reasoning and evidence informed principles including:

‐ the International Classification of Functioning Disability and Health (ICF) model ‐ generic, condition specific, and patient specific outcome measures ‐ diagnostic test accuracy including reliability, validity, sensitivity, specificity, predictive

values and likelihood ratios ‐ prognostic indicators

to analyze the total assessment data and identify the following: ‐ patient’s diagnosis

‐ indications and contraindications to neuromusculoskeletal assessment and treatment

‐ appropriate referral and communication to other members of the health care team in the presence of adverse effects/complications of assessment or of non-mechanical sources of pain indicating further medical assessment

b) Specific:

‐ subjective assessment: ◊ determine a hypothesis of pathology ◊ determine co-existing factors or pre-existing history of trauma ◊ formulate the components of the physical examination based on the subjective

‐ palpation of articular and soft tissue structures

‐ active uniplanar and combined movement tests ‐ passive uniplanar and combined physiological and accessory mobility tests

single plane passive directional stability tests dynamic stability and motor control

‐ neurodynamic and neuromechanosensitivity tests ‐ neurological conduction testing

‐ relevant special tests for the region

For the above section should be able to describe the following: ‐ the relationship of pain, resistance, and spasm

‐ rationale for motion and/or strength limitation ‐ end feels and their relationships to available motion and quality of motion ‐ consistency with the subjective examination

‐ confirmation or negation of the generated hypothesis of pathology ‐ determination of co-existing factors

‐ additional components of the physical examination that need to be done with expected outcomes

10. Conditions:

The emphasis of this course is upper quadrant neuro musculo-skeletal function and dysfunction and the following conditions should be covered via lectures, course manual and/or in case histories: (relate functional findings to underlying pathology) a) General:

‐ capsular and non-capsular lesions ‐ connective tissue injuries - i.e. ligament injuries ‐ bursitis

‐ peripheral articular dysfunction including fixations, instabilities and dislocations


39

‐ peripheral arthritides including rheumatoid arthritis ‐ adverse neurodynamics and mechanosensitivity ‐ non-mechanical pain – e.g.. viscerogenic causes of pain

‐ immobilization stiffness ‐ specific age and or gender related pathologies ‐ fractures

‐ impingements

b) Spinal General: ‐ disc pathology (age related and traumatic lesions, rim lesions)

‐ segmental articular dysfunction: including hypomobilities, hypermobilities/instabilities and fixation

c) Cervical Spine:

‐ cervical radiculopathy

‐ cervical myelopathy ‐ whiplash associated disorder (WAD) including posttraumatic assessment (introductory

case level)

‐ headaches (headache classification, various causes of headache including neuromuscular or articular, clinical features, assessment, differential diagnosis and management) – introductory case level

‐ cervical vascular pathologies: presentation, basic clinical assessment

d) Thorax: ‐ Scheuermann’s Disease, AKS, DISH, Osteoporosis, visceral referral and metastases

‐ disc prolapse ‐ postural dysfunction

‐ hypomobility ‐ Scoliosis

e) Shoulder Girdle:

‐ acromioclavicular joint sprain/dislocation ‐ scapulothoracic restrictions ‐ adhesive capsulitis (idiopathic or post traumatic stiff shoulder)

‐ traumatic/atraumatic anterior instability of the shoulder ‐ rotator cuff pathology – local ‐ calcific tendinitis

f) Elbow:

‐ immobilization stiffness

‐ lateral epicondylalgia as a local condition ‐ instability/dislocation – MCL sprain ‐ olecranon bursitis

g) Wrist and Hand:

‐ Volkman’s ischemic contracture ‐ fractures e.g. Colles’, scaphoid

‐ wrist sprain ‐ triangular fibrocartilage complex (TFCC) lesions ‐ ulnar tunnel syndrome


40

‐ 1st CMC osteoarthritis ‐ 1st MCP sprain (skier’s thumb) ‐ trigger finger

11. Treatment:

b. General: (4 hours) Demonstrate the ability to use clinical reasoning and evidence informed principles to analyze the total examination data to identify the following:

‐ initial treatment regime or alternate action; ‐ generic, condition specific, region specific and patient specific outcome measures

regarding treatment effectiveness in order to progress or modify treatment; ‐ principles of treatment progression and discontinuation;

‐ knowledge of prognostic indicators; risk stratification models ‐ planned prevention program; ‐ appropriate referral and communication to other members of the health care team in the

presence of adverse effects/complications of treatment, or non-mechanical pain indicating further medical assessment

b) Joint Mobilization: (12 hours) *Mobilization is defined as “The skillful active, active assisted and/or passive accessory movement (compression/distraction/glides) of a joint complex within its physiological range of motion.”

i) Types of mobilization: ‐ glides

‐ distraction ‐ osteokinematic ‐ mobilizations with movement

ii) Selection of technique - grade and duration as related to the aims of treatment and stages of healing

iii) Application of technique in all ranges of motion of the joint (relate the indications to the appropriate range of motion for treatment)

iv) Indications and contraindications for the application of mobilization procedures to the upper quadrant including the cervical, thoracic spine and peripheral joints

v) Basic introduction to the principles of the following mobilization approaches:

‐ Maitland ‐ McKenzie ‐ Kaltenborn (Norwegian approach)

‐ Mulligan (NAGS and SNAGS) ‐ Muscle assisted techniques - Muscle Energy Technique (MET), proprioceptive

neuromuscular facilitation (PNF) vi) Effects of mobilization:

b. Joint rheology - effects of mobilization and immobilization on the morphology and physiology of articular cartilage and the degenerative process

c. Joint neurophysiology - effects of mobilization on joint receptors d. Pain - effect of mobilization on:

- mechanical pain - chemical/inflammatory pain - spinal modulation of pain (gate control) - central modulation of pain


41

d. Effects of local mobilization on the normal and abnormal motion states of distal and proximal tissues

c) Manipulation: (2 hours) *Manipulation is defined as: “A skillful passive high velocity, low amplitude thrust movement of a joint (peripheral or spinal) beyond its physiological limit of motion but inside the limit of its anatomical integrity with the purpose of restoring motion and function.” i) Manipulation theory - discuss in detail the indications for manipulation including

theories of joint fixation of the upper quadrant spinal and peripheral joints ii) Types of manipulation:

c. articular glide manipulations a. direct thrust along the line of the articular glide b. parallel to the articular surface c. physiological movement can be used to produce the glide

d. distraction manipulations a. gapping techniques b. perpendicular to the articular surface

iii) Selection of technique Application of technique Indications contraindications and techniques for the application of the following manipulations to the upper quadrant spinal and peripheral joints: ‐ thoracic spine seated axial traction

‐ radiohumeral distraction ‐ ulnohumeral distraction ‐ lunate on radius dorsal and palmar thrusts (dynamic flick)

‐ radioscaphoid distraction iv) Effects of manipulation:

‐ on pain ‐ neurophysiology ‐ muscular

‐ articular ‐ collagen tissue i.e. adhesions

d) Neurodynamic mobilization: (2 hours)

i) Neurodynamic treatment theory ii) Selection of treatment technique iii) Application of technique (basic sliders with one or two basic home exercises) iv) Indications and contraindications v) Effect of neural mobilization on neural mechanosensitivity

e) Case studies using a peripheral upper quadrant case to demonstrate principles of clinical

reasoning in the manual and manipulative physiotherapy treatment approach to abnormal motion states (hypomobilities, hypermobilities, instabilities): (3 hours) i) Joint mobilization/manipulation ii) Basic neural mobilization iii) Exercise therapy

‐ position of optimal postural balance for static and dynamic postures

‐ home exercise program including dynamic postural integration into activities of daily living

‐ muscle imbalance


42

iv) Rationale and indications of adjunct modalities (thermo-, hydro-, electrophysical agents, taping, orthoses)

12. Recording Data: (0.5 hour)

* May be included as a reading assignment Discussions of various standardized forms

13. Physiotherapy Clinical Relevance of Medical Testing/Treatment for the Upper Quadrant

Including: (1 hour)

* May be included as a reading assignment See Level 1 content in this document

14. Current Issues in Physiotherapy (0.5 hour)

‐ current professional issues relevant to the practice of musculoskeletal physiotherapy ‐ jurisprudence (medical-legal issues)

15. Scientific inquiry

* May be included as a reading assignment or discussion to encourage familiarity for the Critical Appraisal course

See Level 1 content in this document

Evaluation Methods


CPA Diploma of Advanced Integrated Musculoskeletal Physiotherapy Program: Policies and Procedures– Education and Examination Standards Document: Version: Jan 2020 Level III Lower Quadrant Curriculum

43

LEVEL 3 – LOWER QUADRANT COURSE

(9 days of face to face course, 1 day of AIM Program online audio power point lectures) Total Hours: 85 hours (83 instruction / 2 examination)

A. PURPOSE:

Course participants will learn the principles, effects, rationale and practical application of advanced lower quadrant neuromusculoskeletal physiotherapy assessment and treatment techniques for the lumbar spine, pelvis and lower extremities, developing an understanding of the interrelationship of proximal and distal tissues (regional interdependence), and normal versus abnormal biomechanics, utilizing evidence-informed clinical reasoning consistent with the ICF and a biopsychosocial model. This course builds on the knowledge and skills learned at Levels 1 and 2.

B. OBJECTIVES:

At the completion of this course, participants will demonstrate competency in: 1. Performance of a detailed subjective and objective neuromusculoskeletal physiotherapy

assessment of the lower quadrant including: observation; active and passive physiological and accessory, and neuromeningeal mobility; muscle length, recruitment, and strength; joint stability; and special tests for each region.

2. Advanced soft tissue and articular assessment and treatment of the lower quadrant integrating principles of grade, direction, duration of techniques, and expected effects.

3. Analyzing and correcting static and dynamic postures of walking and running.

4. Identifying indications and contraindications for all assessment and treatment techniques, evaluating treatment effectiveness, and making changes to progress or modify as appropriate.

5. Analyzing total examination data and integrating knowledge of normal and pathological biomechanics of the lower quadrant, as well as knowledge of etiology and pathogenesis of benign mechanical and degenerative disorders of the lower quadrant, into clinical reasoning to create a treatment rationale

6. Evidence-informed practice including use of outcome measures, prognostic indicators, prevention programs, and appropriate multidisciplinary referrals and communication in the presence of adverse or non-mechanical pathology.

7. Safe and effective performance of high velocity manipulation to specific lower quadrant peripheral and spinal joints.


44

C. TOPICAL OUTLINE:

1. Anatomy:

Encourage student review of AIM Program Lower Quadrant Anatomy on-line audio powerpoints, and brief in class review lecture or quiz. New material introduced in Level 3 Lower: a) Thoracolumbar junction vertebral joints (including discs): Inter and intra regional differences

in zygapophyseal joints and intervertebral discs; detailed osteology, arthrology, myology, neurology , vascularization, function, dynamic and static stability.

2. Biomechanics of Joints and Muscles: (4.5 hours) Encourage student review of AIM program Lower Quadrant Biomechanics on-line audio powerpoints, and brief in class review quiz. Understand the definition and clinical significance of the following for the lower quadrant including the thoracolumbar junction, lumbar spine and pelvic region:

‐ normal biomechanics of gait ‐ advanced functional and dysfunctional biomechanical interrelationship of adjacent joint and

surrounding tissue i.e. lumbo-pelvic-hip relationship, lumbo-pelvic-hip-knee relationship, foot/ankle-knee-hip relationship

‐ theoretical aspects and practical considerations of biomechanical treatment 3. Neurophysiology and Neurobiomechanics:

Encourage student review of AIM program Lower Quadrant Neurodynamics on-line audio power points, and in class review quiz. New material introduced in Level 3 Lower: ‐ peripheral nerve pathology including the effects of injury and disease

‐ interface (container) concepts

4. Myokinematics, Myokinetics and Exercise Physiology: (2 hours) Encourage student review of AIM Program Myokinetics and Exercise Physiology on-line audio powerpoints, and brief in class review quiz.

‐ definition and clinical significance of myokinematics and myokinetics ‐ muscle fiber/tendon partition ration i.e. pennate muscle

‐ motor unit components and motor unit recruitment principles ‐ slow and fast twitch muscle fibers, shunt/spurt action, innervation ratio ‐ anatomy and length/tension relationship (isotonic, isometric, concentric/eccentric

contractions), laws of approximation/detorsion for the lower quadrant ‐ role of the muscles with respect to stability and normal function of the lower quadrant


Review subjective assessment introduced in Levels 1 and 2:


‐ interpretation and hypothesis development on completion of subjective assessment (refer to clinical reasoning reflection form adapted from Jones & Rivett 2003)


Review Level 1 and 2 lower quadrant content including:

‐ Surface anatomy of the lower quadrant (1 hour) ‐ Active physiological mobility tests for the lower quadrant (uniplanar/combined movement

testing) (2 hours)


45

‐ Passive physiological and accessory mobility tests for the lower quadrant (5 hour)

‐ Passive single plane passive tests for the lower quadrant ‐ Neurodynamic and mechanosensitivity tests for the lower quadrant with individual nerve

biasing considering interface issues (1 hour)

‐ Special tests for the lower quadrant (0.5 hour)

New material introduced in Level 3 Lower: a) Muscle length/strength/recruitment tests (5.5 hours)

b) Detailed gait assessment (0.5 hours)

c) Thoracolumbar Junction (TL junction)

i) Observation of the TL junction ii) Surface anatomy of the TL junction:

‐ T10 to L1 spinous and transverse processes ‐ ribs 10 to 12 ‐ erector spinae muscles

◊ Superficial – spinalis, longissimus, iliocostalis ◊ Deep – multifidus, rotatores

‐ levator costorum

‐ quadratus lumborum iii) Active and passive mobility testing of the TL junction:

See thoracic spine content in Level 2 Upper curriculum ‐ locating the transitional region

iv) Stability of the TL junction ‐ distraction and compression

‐ anterior and posterior translation ‐ lateral translation ‐ torsion

7. Analyze the Total Assessment Data: (8 hours)

a) General: Demonstrate the ability to use clinical reasoning and evidence informed principles including:

‐ the International Classification of Functioning Disability and Health (ICF) model ‐ generic, condition specific, and patient specific outcome measures

‐ diagnostic test accuracy including reliability, validity, sensitivity, specificity, predictive values and likelihood ratios

‐ prognostic indicators to analyze the total assessment data and identify the following:

‐ patient’s diagnosis

‐ indications and contraindications to neuromusculoskeletal assessment and treatment appropriate referral and communication to other members of the health care team in the presence of adverse effects/complications of assessment or of non-mechanical pain indicating further medical assessment

b) Specific:

‐ subjective assessment ◊ determine a hypothesis of pathology ◊ determine co-existing factors or pre-existing history of trauma ◊ determine the components of the objective assessment to perform


46


‐ active physiological mobility tests ‐ passive physiological and accessory mobility tests ‐ joint stability and ligament stress tests

‐ muscle length/strength/recruitment tests ‐ neuromeningeal tests ‐ relevant special tests for the region

c) For the above section should be able to describe all of the following:

‐ the relationship of pain, resistance, and spasm ‐ rationale for motion and/or strength limitation

‐ end feels and their relationships to available motion and quality of motion ‐ consistency with the subjective exam

‐ confirmation or negation of the generated hypothesis of pathology ‐ determination of co-existing factors ‐ additional components of the objective assessment that need to be performed with

expected outcomes 8. Conditions: (9 hours)

The emphasis of this course is lower quadrant musculoskeletal function and dysfunction and the following conditions should be covered via lectures, case histories, or home reading assignments that relate functional findings to underlying pathology.

‐ Discussion on central nociplastic mechanisms and clinical pain pattern recognition ‐ joint fixation

‐ instability (spinal and peripheral) ‐ posture dysfunctions ‐ double crush syndromes

‐ peripheral joint loose bodies – review from Lower Quadrant 2 ‐ epiphyseal injuries/diseases ‐ muscular dysfunction including muscle lesions, muscle atrophy, tendinopathy, myositis

ossificans, decreased muscle strength, recruitment or balance ‐ overuse syndromes

‐ trigger points ‐ vascular disorders: abdominal aortic aneurysm, haemophilia ‐ Lower Quadrant autonomic disorders including complex regional pain syndrome

‐ hip syndromes (e.g. labral lesions, femoroacetabular impingement syndrome - FAI) ‐ lumbo-pelvic-hip muscle imbalance syndromes ‐ groin syndromes (differential diagnosis of groin pain)

‐ anterior knee pain syndromes ‐ iliotibial band syndromes

‐ foot deformities, differential diagnosis of heel pain ‐ pathologies affecting the thoraco-lumbar junction: disc herniation with cord versus cauda

equina differentiation, zygapophyseal joint arthrosis with specific considerations for the region

9. Treatment: a) General: (5 hours)

Demonstrate the ability to use clinical reasoning and evidence informed principles to analyze the total examination data to identify the following: ‐ initial treatment regime or alternate action


47

‐ generic, condition specific and patient specific outcome measures regarding treatment effectiveness in order to progress or modify treatment

‐ treatment progression and discontinuation

‐ prognostic indicators; risk stratification models ‐ a planned prevention program ‐ appropriate referral and communication to other members of the health care team in the

presence of adverse effects/complications of treatment or non-mechanical pain indicating medical assessment.


Review active, active assisted and passive physiological and accessory mobilizations procedures covered in Level 2 including:

‐ Types of mobilization - distraction and glides, osteokinematic, mobilizations with movement

‐ Selection of technique - grade and duration as related to the aims of treatment and stages of healing

‐ Application of technique in all ranges of motion of the joint (relate the indications to the appropriate range of motion for treatment)

‐ Indications and contraindications for the application of mobilization procedures to the lower quadrant including lumbar spine and pelvis

‐ Effects of mobilization on joint rheology, joint neurophysiology, and pain

‐ Effects of local mobilization on the normal and abnormal motion states of distal and proximal tissues

c) Manipulation: (10 hours) *Manipulation is defined as: “A skillful passive high velocity, low amplitude thrust movement of a joint (peripheral or spinal) beyond its physiological limit of motion but inside the limit of its anatomical integrity with the purpose of restoring motion and function.”

Review manipulation content covered in Level 2 including: i) Manipulation theory - discuss in detail the indications for manipulation including

theories of joint fixation of the lower quadrant spinal, pelvic, and peripheral joints ii) Types of manipulation:

articular glide manipulations

‐ direct thrust along the line of the articular glide ‐ parallel to the articular surface ‐ physiological movement can be used to produce the glide distraction manipulations ‐ gapping techniques

‐ perpendicular to the articular surface osteokinematic manipulations

iii) Selection of technique iv) Application of technique v) Indications, contraindications, and techniques for the application of manipulation to the

lower quadrant joints. In addition to reviewing all manipulations taught in the Level 2 Lower Quadrant course, the following should be introduced: ‐ superior tibiofibular joint anterior thrust

‐ superior tibiofibular joint posterior thrust ‐ talocrural joint J stroke ‐ subtalar anterior/posterior joint – medial thrust


48

‐ subtalar anterior/posterior joint – lateral thrust

‐ subtalar joint distraction ‐ subtalar joints loose body ‐ mid and forefoot joint distraction, plantar thrust, dorsal thrust, and dynamic flick for

plantar cuboid or navicular ‐ sacroiliac joint supine gap

‐ lumbar spine unilateral extension thrust vi) Effects of manipulation on:

‐ pain ‐ neurophysiology ‐ muscular

‐ articular ‐ collagen tissue i.e. adhesions

‐ the normal and abnormal motion states of distal and proximal tissues

d) Advanced soft tissue mobilization: (20 hours includes Exercise) Muscle lengthening, massage, and soft tissue techniques such as trigger point, adhesion and scar management

‐ Selection of technique ‐ Grade and duration as related to the aims of treatment and stages of healing ‐ Application of technique in the all ranges of motion of the soft tissue (relate to the

indications to the appropriate range of motion for treatment) ‐ Indications and contraindications for the application of soft tissue mobilization

procedures to the lower quadrant

‐ Effect of soft tissue mobilization of tissue mobility and trigger points ‐ Effect of soft tissue mobilization on pain:

◊ mechanical ◊ chemical/inflammatory ◊ spinal modulation of pain (gate control) ◊ central modulation of pain

e) Neural mobilization:

‐ Advanced neural mobilization for the Lower Quadrant using individual nerve biasing

‐ Interface treatment concepts and application

f) Exercise: Practical application of muscle and exercise science in the Lower Quadrant ‐ exercise to increase or maintain range of motion

‐ exercise post ligament or muscle injury ‐ exercise for muscle imbalance, movement reeducation, or stabilization retraining

(Hodges, Hides, Richardson, Jull, Janda, Sahrmann, etc.)

‐ exercise and fitness (improvement or maintenance) ‐ exercise as an adjunct or alternative to manual therapy

‐ postural correction exercise considering position of optimal postural balance (static and dynamic postures)

‐ home exercise programs for treatment or prevention of neuromuscular-articular disorders

g) Non-manual therapy modalities in the lower quadrant: (1 hour)


49

‐ Rationale and indications for adjunct (e.g. thermo-, hydro-, electro-physical agents, taping, orthosis, etc.)

h) Case studies to demonstrate principles of evidence informed clinical reasoning in the

musculoskeletal physiotherapy treatment approach to abnormal motion states (hypomobilities, hypermobilities, instabilities):

‐ manual therapy ‐ neural mobilization

‐ muscle imbalances, motor control and muscle performance impairments ‐ exercise therapy

‐ non-manual therapy modalities

10. Current Issues in Physiotherapy

‐ current professional issues relevant to the practice of musculoskeletal physiotherapy

‐ jurisprudence (medical-legal issues)

11. Scientific inquiry * May be included as a reading assignment for familiarity toward the Critical Appraisal course


Evaluation Methods


CPA Diploma of Advanced Integrated Musculoskeletal Physiotherapy Program: Policies and Procedures– Education and Examination Standards Document: Version: Jan 2020 Level III Upper Quadrant Curriculum

50

LEVEL 3 – UPPER QUADRANT COURSE

(9 days of face to face course, 1 day of AIM program online lectures) Total Hours: 85 hours (83 instruction/2 examination)

A. PURPOSE:

Course participants will learn the principles, effects, rationale and practical application of advanced upper quadrant orthopaedic manual physiotherapy assessment and treatment techniques for the cervical spine, temporomandibular joints, cervicothoracic junction, thorax, and upper extremities, developing an understanding of the interrelationship of proximal and distal tissues, and normal versus abnormal biomechanics, utilizing an evidence informed clinical reasoning approach. This course builds on the knowledge, skills and clinical reasoning learned at Levels 1 and 2.

B. OBJECTIVES:

At the completion of this course, participants will demonstrate competency in: 1. Performance of a subjective and detailed musculoskeletal physiotherapy assessment

including: palpation, active and passive physiological and accessory mobility tests with conjunct movements, and muscular, neuromeningeal and special tests for each region

2. Understanding static and dynamic ergonomics and application to normal and pathological biomechanics of the upper quadrant

3. Integrating principles and practical application of advanced soft tissue and articular assessment and treatment procedures considering grade, direction, duration of techniques and expected effects

4. Integrating principles and practical application of safe and effective high velocity manipulative procedures to specific upper quadrant peripheral and spinal joints

5. Identifying indications and contraindications for all techniques and evaluating treatment effectiveness, making changes to progress or modify as appropriate

6. Analyzing total examination data and integrating knowledge of normal and pathological biomechanics of the upper quadrant and well as knowledge of etiology and pathogenesis of benign mechanical and degenerative disorders of the upper quadrant into clinical reasoning to create a treatment rationale

7. Understanding evidence-informed practice in theory and practical applications, including use of outcome measures, prognostic indicators, prevention programs and appropriate multidisciplinary referrals and communication in the presence of adverse or non-mechanical pathology


51

C. TOPICAL OUTLINE

1. Anatomy:

Encourage student review of AIM Program Upper Quadrant Anatomy on-line audio powerpoints, and brief in class review lecture or quiz. New material introduced in Level 3 Upper: a) cervicothoracic junction vertebral joints (including discs): Inter and intra regional differences

in zygapophyseal joints and intervertebral discs; detailed osteology, arthrology, myology, neurology, vascularization, function, mechanical and functional stability.

b) temporomandibular joint: embryology, osteology, arthrology, myology, neurology, vascularization, function, joint lubrication, mechanical and functional stability

2. Biomechanics of Joints and Muscles

Encourage student review of AIM Program Upper Quadrant Biomechanics on-line audio power points, and brief in class review quiz. Understand the definition and clinical significance of the following for the upper quadrant:

‐ advanced functional and dysfunctional biomechanical interrelationship of adjacent joint and surrounding tissue i.e. cervical – shoulder – thorax - upper extremity - temporomandibular joint

‐ theoretical aspects and practical considerations of biomechanical treatment

3. Neurophysiology and Neurodynamics: Encourage student review of AIM Program Upper Quadrant Neurodynamics on-line audio power points, and in class review quiz. New material introduced in Level 3 Upper:

‐ central nervous system changes related to peripheral nerve injury e.g. homunculus changes ‐ interface (container) concepts

4. Myokinematics and Myokinetics and Exercise Physiology:

Encourage student review of AIM Program Myokinetics and Exercise Physiology on-line audio powerpoints, and brief in class review quiz. See Level 3 Lower content in this document


Review subjective assessment introduced in Levels 1 and 2:


‐ interpretation and hypothesis development on completion of subjective assessment (refer to clinical reasoning reflection form adapted from Jones & Rivett 2003)


Review Level 1 and 2 upper quadrant content including:

‐ Surface anatomy of the upper quadrant ‐ Active physiological mobility tests for the upper quadrant (uniplanar and combined motion)

(4 hours) ‐ Passive physiological and accessory mobility tests for the upper quadrant

‐ Passive single plane stability tests for the upper quadrant ‐ Neurodynamic and neuromechanosensitivity tests of the upper quadrant ‐ Special tests for the upper quadrant


52

New material introduced in Level 3 Upper: a) Differential testing of vertigo with investigation of cervical artery dysfunction according to the

IFOMPT framework

b) Muscle length/strength/recruitment tests for the upper quadrant (e.g. scapular muscles, deep neck flexors. Passive accessory techniques are expected in neutral and at the end of available range, in assessment and in treatment.

c) Temporomandibular Joint (TMJ) Assessment: i) Observation of the TMJ ii) Surface anatomy of the TMJ

‐ temporomandibular joint line ‐ mandibular angle

‐ zygomatic arch ‐ muscles: temporalis, masseter, medial and lateral ptyergoid, suprahyoid

iii) Active and passive mobility testing of the TMJ iv) Passive single plane stability testing of the TMJ

‐ anterior translation ‐ posterior translation

‐ lateral translation v) Pain provocation testing

‐ distraction and compression vi) TMJ muscle length, strength, recruitment tests vii) Special tests for the TMJ e.g. disc grind

d) Cervicothoracic (CT) Junction

v) Observation of the CT junction vi) Surface anatomy of the CT junction vii) Active and passive mobility testing CT junction viii) Joint stability of the CT junction:

‐ anterior and posterior translation ‐ lateral translation ix) Pain provocation testing of the CT junction

‐ distraction and compression x) CT junction muscle length, strength, recruitment tests xi) Special tests – Thoracic Outlet tests

e) Thorax i) Costal components – anterior and posterior

e) Special tests

‐ Elbow: posterolateral rotatory instability test (Streubel 2014)

‐ As discussed in the clnical manual ‐

7. Analyze the total examination data (10 hours)

a) General: Demonstrate the ability to use clinical reasoning and evidence informed principles including: ‐ the International Classification of Functioning Disability and Health (ICF) model

‐ generic, condition/region specific, and patient specific outcome measures


53

‐ diagnostic test accuracy and reliability

‐ diagnostic test accuracy including reliability, validity, sensitivity, specificity, predictive values and likelihood ratios

‐ prognostic indicators

to analyze the total assessment data and identify the following: ‐ patient’s diagnosis

‐ indications and contraindications to manual therapy assessment and treatment ‐ appropriate referral and communication to other members of the health care team in the

presence of adverse effects/complications of assessment or of non-mechanical pain indicating further medical assessment

b) Specific:


‐ active physiological mobility tests (combine / conjunct motion) ‐ passive physiological and accessory mobility (combine / conjunct motion) ‐ joint stability and ligament stress tests

‐ muscle length/strength/recruitment tests ‐ neuromeningeal tests ‐ relevant special tests for the region

c) For the above section should be able to describe the following:

‐ the relationship of pain, resistance, and spasm

‐ rationale for motion and/or strength limitation ‐ end feel and their relationships to available motion and quality of motion ‐ consistency with subjective examination

‐ confirmation or negation of the generated hypothesis of pathology ‐ further determination of co-existing factors ‐ additional components of the physical examination that need to be done with expected

outcomes

8. Conditions (6.5 hours)

The emphasis of this course is upper quadrant musculoskeletal function and dysfunction and the following conditions should be covered via lectures, case histories or a home reading assignments that relate functional findings to underlying pathology.

‐ Discussion on central nociplastic mechanisms and clinical pain pattern recognition ‐ Joint fixations

‐ Instabilities (spinal and peripheral) ‐ Peripheral joint loose bodies ‐ Faulty posture

‐ Double crush syndromes ‐ Epiphyseal injuries and diseases ‐ Muscular dysfunction including muscle lesions, atrophy, tendinopathy, myositis ossificans,

weakness, recruitment, or balance ‐ Overuse syndromes

‐ Trigger points ‐ segmental facilitation ‐ compartment syndromes


54

‐ vascular disorders: angina, migraine, Volkmann’s ischemic contracture, Raynaud’s disease, hypertension, aneurysms, haemophilia

‐ neural mechanosensitivity

‐ spinal cord, brain stem, cerebellum, cortex vascular insufficiency ‐ cervicogenic headache ‐ wry neck/torticollis

‐ Dizziness/vertigo/balance disorders: cervical spondylogenic, vestibulocochlear nerve, endolymphatic disorders (Meniere’s disease), vascular disorders (cervical artery dysfunction), hypotension, cerebellar disease, otitis media

‐ Assessment and treatment of Somatosensory Dysfunction

‐ Temporomandibular Disorders (TMD) ‐ SLAP, Bankart, Hill-Sack’s, rotator cuff pathology, impingement

‐ thoracic outlet syndrome ‐ Pancoast tumour ‐ Horner’s syndrome

‐ Upper Quadrant autonomic disorders including complex regional pain syndrome and T4 syndrome

‐ De Quervain’s tenosynovitiis ‐ lateral/medial epicondylagia syndromes ‐ carpal tunnel syndrome

‐ carpal instabilities: volar intercalated segment instability (VISI) and dorsal intercalated segment instability (DISI)

9. Treatment

a) General: (4 hours) Demonstrate the ability to use clinical reasoning and evidence informed principles to analyze the total examination data to identify the following: ‐ initial treatment regime or alternate action

‐ generic, condition/region specific and patient specific outcome measures regarding treatment effectiveness in order to progress or modify treatment

‐ principles of treatment progression and discontinuation ‐ prognostic indicators; risk stratification models ‐ a planned prevention program

‐ appropriate referral and communication to other members of the health care team in the presence of adverse effects/complications of treatment, or non-mechanical pain indicating medical assessment


Review active, active assisted, and passive physiological and accessory procedures covered in Level 2 including: ‐ Types of mobilization - distraction and glides, osteokinematic, mobilizations with

movement ‐ Selection of technique - grade and duration as related to the aims of treatment and

stages of healing ‐ Application of technique in all ranges of motion of the joint (relate the indications to the

appropriate range of motion for treatment)

‐ Indications and contraindications for the application of mobilization procedures to the upper quadrant including spinal concerns

‐ Effects of mobilization on joint rheology, joint neurophysiology, and pain


55

‐ Effects of local mobilization on the normal and abnormal motion states of distal and proximal tissues

c) Manipulation: (6 hours)

*Manipulation is defined as: “A skillful passive high velocity, low amplitude thrust movement of a joint (peripheral or spinal) beyond its physiological limit of motion but inside the limit of its anatomical integrity with the purpose of restoring motion and function.”

Review manipulation content covered in Level 2 including: i) Manipulation theory - discuss in detail the theories of indications for manipulation of

the upper quadrant spinal and peripheral joints ii) Types of manipulation:

articular glide manipulations ‐ direct thrust along the line of the articular glide

‐ parallel to the articular surface ‐ physiological movement can be used to produce the glide distraction manipulations

‐ gapping techniques ‐ perpendicular to the articular surface osteokinematic manipulations

iii) Selection of technique iv) Application of technique v) Indications, contraindications, and techniques for the application of manipulations to

the upper quadrant joints. In addition to reviewing all manipulations taught in the Level 2 Upper Quadrant course, the following should be introduced:

‐ ulnohumeral lateral translation ‐ ulnohumeral adduction (osteokinematic thrust) - optional

‐ elbow loose body ‐ proximal radioulnar joint anterior and posterior translation ‐ ulnar disc dorsal translation

‐ distraction: radiocarpal, ulnocarpal, midcarpal, CMC, MCP, IP ‐ Mill’s manipulation

‐ mid-cervical specific traction ‐ Thoracic spine (T3-9) bilateral zygapophyseal joint bilateral flexion and bilateral

zygapophyseal joint bilateral extension - specific supine technique

d) Advanced soft tissue mobilization: (14.5 hours includes Exercise)

Muscle lengthening, massage, soft tissue techniques such as trigger point, adhesions and scar management ‐ Selection of technique

‐ Grade and duration as related to the aims of treatment and stages of healing ‐ Application of technique in all ranges of motion of the soft tissue ‐ Indications and contraindications for the application of soft tissue mobilization

procedures to the upper quadrant

‐ Effect of soft tissue mobilization on tissue mobility and trigger points ‐ Effect of soft tissue mobilization on pain:

◊ mechanical ◊ chemical/inflammatory ◊ spinal modulation of pain (gate control)


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◊ central modulation of pain

h) Neuromeningeal mobilization: ‐ Advanced neuromeningeal mobilization for the Upper Quadrant using individual nerve

biasing ‐ Interface treatment concepts and application

i) Exercise:

Practical application of muscle and exercise science in the Upper Quadrant

‐ exercise to increase or maintain range of motion ‐ exercise for vestibular rehabilitation / somatosensory dysfunction

‐ exercise post ligament or muscle injury ‐ exercise and muscle imbalance, movement reeducation, or stabilization retraining

(Hodges, Jull, Janda, Sahrmann, etc.)

‐ exercise and fitness (improvement or maintenance) ‐ exercise as an adjunct or alternative to manual therapy

‐ postural correction exercise considering position of optimal postural balance (static and dynamic postures)

‐ home exercise programs for treatment or prevention of neuro-muscular-articular disorders of the upper quadrant

j) Other modalities in the upper quadrant: (1 hour)

‐ Rationale and indications for adjunct (e.g. thermo-, hydro-, electro-physical agents, taping, orthosis, etc.)

i) Case studies to demonstrate principles of evidence informed clinical reasoning in the

musculoskeletal treatment approach to abnormal motion states (hypomobilities, hypermobilities, instabilities):

‐ manual therapy ‐ neuromeningeal mobilization

‐ muscle imbalances, motor control and muscle performance impairments ‐ exercise therapy

‐ non-manual therapy modalities 12. Current Issues in Physiotherapy (0.5 hour)

‐ current professional issues relevant to the practice of musculoskeletal physiotherapy

‐ jurisprudence (medical-legal issues)

13. Scientific inquiry * May be included as a reading assignment for familiarity toward the Critical Appraisal course


Evaluation Methods


CPA Diploma of Advanced Integrated Musculoskeletal Physiotherapy Program: Policies and Procedures– Education and Examination Standards Document: Version: Jan 2020 Level IV Vertebral Curriculum

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LEVEL 4 - VERTEBRAL JOINT COURSE (5 days)

Total Hours: 35 hours (35 instruction)

A. PURPOSE

To teach the treatment of spinal, pelvic and costal joint dysfunction safely and effectively by manipulation* techniques with emphasis on clinical reasoning and the indications and contraindications for their use. * Manipulation is defined as a skillful passive high velocity, low amplitude thrust movement

of a joint (peripheral or spinal) beyond its physiological limit of motion but inside the limit of its anatomical integrity with the purpose of restoring motion and function.

B. OBJECTIVES

At the completion of this course participants will be able to: 1. Analyze examination data to establish the indications and contraindications for the use

of high velocity, low amplitude thrust techniques to the spinal column, pelvis and costal joints;

2. Understand the theories of spinal joint fixation; 3. Understand the theory of high velocity, low amplitude thrust techniques to the spinal,

pelvic and costal region; 4. Apply high velocity, low amplitude thrust techniques to specific spinal, pelvic and costal

joint dysfunction; 5. Integrate high velocity, low amplitude thrust techniques into the treatment regime for the

correction of spinal, pelvic and costal dysfunction; 6. Develop an understanding of evidence informed practice with regards to the theory and

practical application of discussed diagnostic testing (assessment) and treatment techniques including: a. generic, condition specific and patient specific outcome measures regarding

treatment effectiveness in order to progress or modify treatment; b. knowledge of prognostic indicators; c. a planned prevention program; d. appropriate referral and communication to other members of the health care team

in the presence of adverse effects/complications of assessment and / or treatment.

C. TOPICAL OUTLINE

1. Analyze Examination Data: (9 hours) a. review biomechanics and examination as per Level II & III Upper and Lower

Quadrants. b. review clinical musculoskeletal anatomy and clinical relevance of the same, including

neurovascular anatomy of spinal, pelvic and costal joints and their related central and peripheral neurological innervation as well as neurological tests of their function.

2. Demonstrate the ability to use clinical reasoning and evidence informed principles in the

discussion of the following: (6 hours) a. determination of the patient’s diagnosis b. theories of joint fixation of the spinal pelvic and costal joints c. philosophies, indications and contraindications of high velocity, low

amplitude thrust techniques of the spinal, pelvic and costal joints d. conditions of central circulatory insufficiency and craniovertebral instability


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e. generic, condition specific and patient specific outcome measures regarding treatment effectiveness in order to progress or modify treatment

f. the principles of treatment progression and discontinuation g. prognostic indicators h. the appropriate referral and communication to other members of the health care

team in the presence of adverse effects/complications of assessment and / or treatment

i. a cause and a planned prevention program.

3. Instruct high velocity, low amplitude thrust techniques to each mobile segment of the spine: Cranio-vertebral: (1 hour) a. OA distraction b. AA distraction Cervical: (4 hours) a. zygapophyseal joint unilateral distraction b. zygapophyseal joint unilateral inferior translation (extension glide) c. zygapophyseal joint unilateral superior translation (flexion glide) d. osteokinematic (flexion rotation) Cervico-thoracic Junction: (2 hours) a. C7-T3 zygapophyseal joint bilateral superior translation (glide)

1) non-specific sitting technique 2) specific supine technique

Thoracic: (4 hours)

a. T3-9 segmental manipulation: bilateral zygapophyseal joint superior translation (flexion glide) and intervertebral disc joint distraction

1) non-specific sitting technique (i.e. with towel roll localization) 2) specific supine technique

b. T3-9 zygapophyseal joint bilateral inferior translation (extension glide): 1) specific supine technique

c. T3-12 zygapophyseal joint unilateral inferior translation (extension glide) d. T3-12 zygapophyseal joint unilateral superior translation (flexion glide) Lumbar: (4 hours)

a. zygapophyseal joint unilateral oblique distraction (gap) (review) b. zygapophyseal joint unilateral superior translation (flexion glide) c. zygapophyseal joint unilateral inferior translation (extension glide) (review) Pelvic Joints (3 hours)

a. sacroiliac joint unilateral distraction - supine technique (review) b. sacroiliac joint unilateral innominate superior translation (glide) (review) c. sacroiliac joint unilateral innominate inferior translation (glide) - prone & supine

techniques (review) d. side lying unilateral innominate posterior rotation e. prone unilateral innominate anterior rotation f. prone unilateral anterior glide (nutation)


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g. prone unilateral posterior glide (counternutation) Costal Joints (1 hour)

a. first rib costo-transverse joint inferior translation (‘inspiration’ glide) b. first rib costo-transverse joint distraction (gap) c. 2-10 costo-transverse joint distraction

4. Integration into Total Treatment Program: (5.5 hours)

Instruct the integration of high velocity, low amplitude techniques as adjunctive therapy in the correction of spinal, pelvic and costal dysfunction.

5. Discuss the legal and ethical considerations in the use of high velocity, low amplitude

thrust techniques. (1 hour) * may be included as a reading assignment

6. Current Issues in Physiotherapy (0.5 hour)

a. current professional issues relevant to the practice of musculoskeletal physiotherapy. Please consider and inform regarding relevant provincial regulations surrounding i.e. rostering

b. jurisprudence (medical-legal issues with reference to CAMPT written consent document). Please consider and inform regarding relevant provincial regulations surrounding consent to treat. An on-line audio power point will be available for student review regarding the legal aspects of informed consent.

7. Scientific inquiry

To enhance the knowledge of the theory of musculoskeletal physiotherapy practice and encourage critical review of its scientific merit there must be an understanding the following basic principles:

1) epidemiology (populations, samples, allocation of subjects) 2) the terms validity/ reliability/ variables/ pre post- test probability, sensitivity/

specificity, likelihood ratios) 3) biomedical statistics (descriptive and inferential; parametric and non-parametric) 4) research methodology and design (measurement; experimental, quasi- experimental

and non-experimental) 5) ethics in research 6) methods of literature searches

7) scientific inquiry in clinical practice and with writing / reading scientific papers.

CPA Diploma of Advanced Integrated Musculoskeletal Physiotherapy Program: Policies and Procedures– Education and Examination Standards Document: Version: Jan 2020 Level V Vertebral Curriculum

60

LEVEL 5 - VERTEBRAL JOINT COURSE (5 days)

Total Hours: 35 hours (35 instruction) Note: Examination is the Advanced Orthopaedic Manual and Manipulative Physiotherapy Examination A. PURPOSE

To teach the assessment and treatment of spinal, pelvic and costal joint dysfunction safely and effectively by advanced manipulation* techniques. An emphasis will be placed on the clinical reasoning integration of the mechanical and anatomical influences of local and distal tissues. Assessment and treatment technique indications and contraindications of use will also be emphasized. * Manipulation is defined as a skillful passive high velocity, low amplitude thrust movement of a joint (peripheral or spinal) beyond its physiological limit of motion but inside the limit of its anatomical integrity with the purpose of restoring motion and function.

B. OBJECTIVES

At the completion of this course participants will be able to: 1. Analyze examination data to establish the indications and contraindications for the use

of advanced high velocity, low amplitude thrust techniques to the spinal column, pelvis and costal joints

2. Apply advanced high velocity, low amplitude thrust techniques to specific spinal, pelvic and costal joint dysfunction

3. Apply advanced high velocity, low amplitude thrust techniques to specific spinal, pelvic and costal joint dysfunction in the presence of proximal or distal hypermobilities, instabilities and / or adverse neuromeningeal tension

4. Integrate advanced high velocity, low amplitude thrust techniques into the treatment regime for the correction of spinal, pelvic and costal dysfunction

5. Develop an understanding of evidence informed physiotherapy practice with regards to the theory and practical application of discussed diagnostic testing (assessment) and treatment techniques including: a. generic, condition specific and patient specific outcome measures regarding

treatment effectiveness in order to progress or modify treatment b. knowledge of prognostic indicators c. a cause and a planned prevention program d. appropriate referral and communication to other members of the health care team

in the presence of adverse effects/complications of assessment and / or treatment.

C. TOPICAL OUTLINE

1. Demonstrate the ability to use clinical reasoning and evidence informed principles in the discussion of the following: (2 hours) a. analysis of examination data to establish the patient’s diagnosis; b. analysis of the examination data to establish the indications and contraindications

for the use of advanced high velocity, low amplitude thrust techniques to the spinal column, pelvis and costal joints;

c. appropriate referral and communication to other members of the health care team in the presence of adverse effects/complications of assessment and /or treatment.


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2. Instruct Advanced High Velocity, Low Amplitude Thrust Techniques to each mobile segment of the spine: Cranio-vertebral: (4 hours) a. OA distraction (review) b. AA distraction (review) c. OA unilateral anterior translation (extension glide) (appendix) d. OA unilateral posterior translation (flexion glide) e. AA unilateral anterior translation (glide) f. AA unilateral posterior translation (glide) Cervical: (4 hours)

a. zygapophyseal joint unilateral distraction (review) b. zygapophyseal joint unilateral inferior translation (extension glide)

1) review 2) manipulation techniques in the presence of hypermobility (instability) above

or below the joint be manipulated and / or in the presence of adverse neuromeningeal tissue mobility

c. zygapophyseal joint unilateral superior translation (flexion glide) 1) review 2) when level above joint to be manipulated is hypermobile (unstable) 3) when level below joint to be manipulated is hypermobile (unstable)

d. uncovertebral joint unilateral translation to restore right sidebend (medial translation glide)

e. uncovertebral joint unilateral translation to restore left sidebend (medial translation glide)

Cervio-thoracic: (1 hour) a. C7-T3 zygapophyseal joint bilateral superior translation (glide)

1) non-specific sitting technique (review) 2) specific supine technique (review)

b. C7-T3 zygapophyseal joint unilateral inferior translation (extension glide) c. C7-T3 zygapophyseal joint unilateral superior translation (flexion glide) d. manipulation techniques in the presence of hypermobility (instability) above or

below the joint be manipulated and / or in the presence of adverse neuromeningeal tissue mobility

Thoracic: (2 hours) a. manipulation techniques in the presence of hypermobility (instability) above or

below the joint be manipulated and / or in the presence of adverse neuromeningeal tissue mobility

Lumbar: (2 hours)

a. manipulation techniques in the presence of hypermobility (instability) above or below the joint be manipulated and / or in the presence of adverse neuromeningeal tissue mobility

Pelvic joints (4 hours) a. sacroiliac joint unilateral anterior glide (unilateral sacral nutation)

1) prone technique b. sacroiliac joint glide, unilateral innominate posterior rotation


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1) supine techinique 2) side lying technique c. sacroiliac joint unilateral posterior glide (unilateral sacral counternutation)

1) prone technique - review 2) side lying technique d. sacroiliac joint unilateral innominate anterior rotation - parallel

1) prone technique - review 2) side lying technique e. sacroiliac joint unilateral distraction

1) supine technique (review) 2) side lying technique f. manipulation techniques in the presence of hypermobility (instability) above or

below the joint to be manipulated and / or in the presence of adverse neuromeningeal tissue mobility

Costal: (2 hour)

a. 1-10 costo-transverse joint distraction (review)

3. Integration into Total Treatment Program: (13.5 hours) a. instruct the integration of advanced high velocity, low amplitude techniques as

adjunctive therapy in the correction of spinal, pelvic and costal dysfunction. b. case history scenarios for each region: review history features, assessment and

treatment of all tissues (articular, muscular, neuromeningeal, vascular). include the following:

1) generic, condition specific and patient specific outcome measures regarding treatment effectiveness in order to progress or modify treatment;

2) principles of treatment progression and discontinuation; 3) prognostic indicators; 4) attributing a cause and planning a prevention program; 5) appropriate referral and communication to other members of the health

care team in the presence of adverse effects/complications of assessment .

4. Current Issues in Physiotherapy (0.5 hour) a. current professional issues relevant to the practice of musculoskeletal

physiotherapy b. jurisprudence (medical-legal issues) c. students should be directed to on-line audio power point regarding patient informed

consent

5. Scientific inquiry To enhance the knowledge of the theory of musculoskeletal physiotherapy practice and encourage critical review of its scientific merit there must be an understanding the following basic principles: 1) epidemiology (populations, samples, allocation of subjects)

2) the terms validity/ reliability/ variables/ pre post-test probability, sensitivity/ specificity, likelihood ratios)

3) biomedical statistics (descriptive and inferential; parametric and non-parametric) 4) research methodology and design (measurement; experimental, quasi-

experimental and non-experimental) 5) ethics in research 6) methods of literature searches

7) scientific inquiry in clinical practice and with writing/reading scientific papers.


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VIII. ON-LINE CRITICAL APPRAISAL AND RESEARCH DESIGN (10 weeks) Total Hours: 35 hours (35 instruction)

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