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  • Rob

2016 Level 2 Lower

This past weekend, I was in Vancouver, at UBC, helping to teach the introductory weekend of the Level 2 Lower course. You have read a few blog posts about me helping out with the Level 2 Upper courses and where they fit into the curriculum of the Orthopaedic Division postgraduate courses. In my career, I have helped/assisted on the Level 2 Upper courses at a minimum 7 times, the Level 2 Lower courses over the same time period 2-3 times, only. For some reason, I keep getting the Upper courses. Well this weekend, I was lucky enough to get this course. And what could be luckier, you ask? I was asked to help teach this weekend, not assist!!!

The prep work for this weekend started back at the end of February 2016. I talked with the other physiotherapist teaching the course, Sherrill. Since it was my first weekend EVER, teaching on this course. She asked me which sections I would like to teach. Let me back up a little bit… The Level 2 Lower course encompasses from the low back down. The complete course covers the lumbar spine, pelvis, hips, knees, ankles and feet are included. This course is 12 days long, 4, 3 day weekends. This first weekend we were going to teach the lumbar spine and neurodynamics (how the nervous system moves).

I decided to teach the lumbar spine anatomy, biomechanics, joint stability testing, passive range of motion grading and choice of grades, neurodynamics and neurodynamic testing. Oh yes, surface anatomy of the lumbar spine. Sherrill thought I was taking on quite a bit and I think she was right. There were a lot of theory lectures in my choosing. Those are the more difficult ones to teach as the physiotherapists taking the course can easily get bored. For example, lumbar spine anatomy is very important to teach because assessment and treatment are simply extensions of the anatomy. But to sit and listen to a lecture about anatomy for an hour is not very exciting. I tried to put in bits and pieces of why things are clinically relevant in the lecture. However, it was my first lecture and yes I did have lecture notes and I did practice the talk at least 5 times before actually giving the talk, I forgot a bunch of them. :(

There were a couple of questions from the group which is always encouraging because that means they were listening.

Oh yes, Ryan from Sun God Physiotherapy and Fortius, was there as an assist on the course and he was excellent.

Friday afternoon, I gave the first 3 lectures to the group, lumbar spine anatomy, surface anatomy and biomechanics of the lumbar spine. Those might be good blog posts to educate readers on their low backs. Our low back are our Achilles heels, the price we pay for walking upright. They say that 80% of people get low back pain in the lifetime. The other 20% of people, simply forgot about the time they had low back pain. Teaching the newish physios about the low back is pretty important stuff. Sherrill gave me some good feedback on how to change some things in my presentations to engage the audience a little bit more. I tried to change, slightly, a couple of subsequent presentations to get people more engaged/ attentive.

"...80% of people get low back pain in the lifetime. The other 20% of people, simply forgot about the time they had low back pain..."

We finished off Friday night with Sherrill starting the lumbar spine neurological assessment.

Saturday was a brand new day! We had some great discussions about end-feels. What are end-feels you ask? An end-feel is what the physiotherapist feels when pushing into their client’s body when assessing a joint or a muscle. For example, when a physiotherapist assesses how a joint in the spine moves, if it is moving normally/without a restriction, the joint capsule will be the main cause of resistance at the end of the motion. This would give, what we call, a capsular end-feel. However, say were we assessing a joint in the low back of someone that slipped and fell yesterday and was still sore today. We test the joint glide and if that joint was injured, the muscles would try to protect that joint, giving a muscle spasm. That type of end-feel is called a muscle spasm end-feel. There are at least 5-6 different types of end-feels. To go through them all and explain them sounds like another great blog post. It does take time to build up the ability to detect the different end-feels even when practicing full-time.

We talked about lumbar posture and active range of motion. It was interesting to watch a bunch of “normal” physiotherapists move. Even though most people did not have any pain in their low backs, everybody seemed to move through a slightly different pattern. Some people moved through their hips before low back, others barely moved through their hips and some had very flexible low backs. It was great to walk through the physiotherapists assess each other and help them to ‘see’ what their were seeing.

Stability testing of the lumbar spine was up next. I gave a little bit of the history of stability testing and Punjabi’s model (3 components, Active, Passive and Control tissues) of stability which is used by the Orthopaedic Division to explain why we have stable spines. Then we went through actually doing the stability tests as passive and dynamic. It was great to see the course participants could feel the difference. Really good, practical session that created a lot of excellent discussion from the naming of the tests, through that actual performing the tests and what is felt while doing the tests.

We finished off Saturday with teaching some positional testing of the lumbar spine, went through the different grades and how to choose the different grades of mobilization of peripheral and spinal joints and locking of the lumbar spine, theory and practical sessions.

The Sunday sessions seemed to fly by. The day started off with a review of what we had covered so far that weekend. Sherrill had some handouts for the students on inflammatory vs. mechanical pain. This can be very helpful in the clinic when talking with clients. This progressed into talking about the muscles of the lumbar spine specifically transversus abdominis and multifidus. These two muscles are very important in people with low back pain. Within 24 hours of getting low back pain, the specific pain levels in the back of the multifidus stop working!! We do not know why but it occurs and the scary thing is that these muscles DO NOT start working again automatically after the pain has gone way. The multifidus muscles have to be trained to come back on. This maybe why people have weak spots in their backs after and injury if they do not see a physiotherapist for rehabilitation. In addition, transversus abdominis (TA) is the deepest abdominal muscle we have. It is also affected by low back pain.

Both multifidus and TA are anticipatory muscles. This means that the muscles actually fire and stabilize the body before we actually move. If I really stop and start to think about it, that is pretty amazing! If you are standing and think of walking to the sink to get a glass of water, before you move your leg, those two muscles are turned on and stabilizing your back and abs! That is so cool! What I forgot to mention is that TA muscle activation changes with low back pain as well. Instead of contracting before movement, TA activates after the movement has occurred. There is no pre stabilization for movement. Just like multifidus, this does not automatically return to normal when the pain is gone. Going to see a physiotherapist, they can get you are a basic core program to get your multifidus and TA working again (just a little commercial for the profession :) ). Sherrill talked about lumbar spine conditions, the big two were disc bulges and osteoporosis (bones becoming fragile).

I was back on stage and did a lecture on neurodynamics. Neuro...what? Neurodynamics is not only about the movement of the nerves and the nervous system inside the body but the physiology that allows the nervous to move they way it does in the body. Did you know depending on your position, the nerves in the low back, lumbar spine, can move up to 5 cm!! There is a bunch of elasticity built into the nervous system so that nerves do not tear as we go through a bunch of varied positions throughout the day. Neurodynamics is definitely an upcoming blog post, it is very neat and interesting material. Sherrill led the group through peripheral nerve palpation, literally getting on someone else’s nerves, but in a good way. It was interesting, the physiotherapists that were having back or leg pain, touching their nerves were much more tender and would given some shooting pains. This was different from the physiotherapists that did not have any pain, even with “flicking” the peripheral nerves there was no pain.

After lunch, the day was finished off with doing some neurodynamic testing. We focused on the basic tests of the slump test, the straight leg raise test and the prone knee bend. Lots of discussion about the tests and there are so many variations on how to do the tests. The physiotherapists enjoyed the commentary and problem solving scenarios. By that time, we were done the course. I think just about everybody left with their brains full from a weekend of great learning, including myself. My only regret for the weekend, is that I did not take many pictures of the physiotherapists taking the course practicing and problem solving.

Here`s to the next course, I get to help out with, thank you!

If you are having some low back pain, pain down your leg or any other issue. We would like to help work with you through your injury towards optimum health, in the comfort of your home. Contact New Leaf Physiotherapy here, a mobile Kelowna physio clinic.

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