tag:typepad.com,2003:weblog-1250480 %ISSUE_DATE%T09:25:32-07:00 Focus on hardware and diagnostics. TypePad tag:mpamedia.com,2008:post-56483 2013-05-15T12:00:32-07:00 2013-05-15T12:00:07-07:00

I have written previously regarding the difficulties of drawing information from patients who are poor historians, forgetful or just plain uncooperative. The thought to revisit the topic occurred recently during preparation for an upcoming seminar. Cases I am preparing to present reminded me of how often this problem occurs and how difficult it can make our jobs. In this account, I will describe a few sample cases to illustrate the problem. Radiographs accompany the first two cases.

By K. Jeffrey Miller, DC, DABCO I have written previously regarding the difficulties of drawing information from patients who are poor historians, forgetful or just plain uncooperative. The thought to revisit the topic occurred recently during preparation for an upcoming seminar. Cases I am preparing to present reminded me of how often this problem occurs and how difficult it can make our jobs. In this account, I will describe a few sample cases to illustrate the problem. Radiographs accompany the first two cases. tag:mpamedia.com,2008:post-56454 2013-04-15T12:00:32-07:00 2013-04-15T12:00:07-07:00

First, treatment without diagnosis is irresponsible, in my opinion. It's almost like going to a pharmacist and asking for a medication. That pharmacist does not have the clinical ability to diagnose you, but right behind them they can dispense a �¢??potpourri" of things to make you feel different.

By Robert "Skip" George, DC, CCSP, CSCS First, treatment without diagnosis is irresponsible, in my opinion. It's almost like going to a pharmacist and asking for a medication. That pharmacist does not have the clinical ability to diagnose you, but right behind them they can dispense a �¢??potpourri" of things to make you feel different. tag:mpamedia.com,2008:post-56445 2013-05-01T12:00:32-07:00 2013-05-01T12:00:07-07:00

It seems each managed care company or insurance company has its own idea as to what appropriate patient care looks like. Most of their protocols are developed internally; some without any reference to published literature and others influenced by outdated or incomplete literature. In addition, often the protocols that were designed for a specific patient population are used to manage other patient groups. For instance, it is very common for insurers to use uncomplicated acute care models even when dealing with chronic cases or cases with various complicating factors.

It seems each managed care company or insurance company has its own idea as to what appropriate patient care looks like. Most of their protocols are developed internally; some without any reference to published literature and others influenced by outdated or incomplete literature. In addition, often the protocols that were designed for a specific patient population are used to manage other patient groups. For instance, it is very common for insurers to use uncomplicated acute care models even when dealing with chronic cases or cases with various complicating factors. tag:mpamedia.com,2008:post-56441 2013-04-01T12:00:32-07:00 2013-04-01T12:00:07-07:00

As many prospective students do, I toured different schools to choose where to pursue my chiropractic education. I recall one presentation by an instructor that was distinctly not what I expected - he talked not so much about the spine, but all the other ways chiropractic can help the body. He talked about active rehab, different therapy modalities, and supportive braces. The part of his presentation I most recall is this old country doc talking about how he would tape a half dollar over the heel to reduce a heel spur and provide relief.

By Douglas R. Briggs, DC, Dipl. Ac. (IAMA), DAAPM As many prospective students do, I toured different schools to choose where to pursue my chiropractic education. I recall one presentation by an instructor that was distinctly not what I expected - he talked not so much about the spine, but all the other ways chiropractic can help the body. He talked about active rehab, different therapy modalities, and supportive braces. The part of his presentation I most recall is this old country doc talking about how he would tape a half dollar over the heel to reduce a heel spur and provide relief. tag:mpamedia.com,2008:post-56405 2013-03-15T12:00:32-07:00 2013-03-15T12:00:07-07:00

Consistent, current and complete health care documentation is an essential component of quality patient care. Practitioners are required to maintain uniform, organized records containing patient demographics, history and treatment information. To facilitate communication and promote efficient and effective treatment, Medicare has implemented the Physician Quality Reporting System (PQRS). This program will be mandatory beginning in 2015. For the 2013 PQRS reporting period, two measures are required for chiropractors: Pain Assessment and Functional Outcome Assessment.

By Ronald Feise, DC and J. Michael Menke, MA, DC, PhD Consistent, current and complete health care documentation is an essential component of quality patient care. Practitioners are required to maintain uniform, organized records containing patient demographics, history and treatment information. To facilitate communication and promote efficient and effective treatment, Medicare has implemented the Physician Quality Reporting System (PQRS). This program will be mandatory beginning in 2015. For the 2013 PQRS reporting period, two measures are required for chiropractors: Pain Assessment and Functional Outcome Assessment. tag:mpamedia.com,2008:post-56341 2013-02-01T12:00:32-07:00 2013-02-01T12:00:07-07:00

Here's a scary statistic: Americans born in 2000 or later have a lifetime risk of more than one in three of developing type 2 diabetes. The problem extends across the world, with increasing cases of diabetes in developed and developing nations like the U.K., China and the Arab Emirates.

By Marco Lopez, DC, CCEP Here's a scary statistic: Americans born in 2000 or later have a lifetime risk of more than one in three of developing type 2 diabetes. The problem extends across the world, with increasing cases of diabetes in developed and developing nations like the U.K., China and the Arab Emirates. tag:mpamedia.com,2008:post-56300 2013-01-01T12:00:32-07:00 2013-01-01T12:00:07-07:00

The first metatarsophalangeal joint includes four bones. The most readily apparent portion of the joint is the articulation between the concave-shaped base of the proximal phalanx and the convex, rounded head of the first metatarsal. The plantar surface includes the two sesamoid bones (fibular or lateral and tibial or medial) and the joint capsule. The joint capsule is reinforced on its plantar aspect by both a fibrocartilagenous plate and the plantar accessory ligament. The flexor hallucis longus and flexor hallucis brevis attach on the plantar aspect, along with the abductor hallucis muscle and the adductor hallucis muscle. The hallux MTP sesamoids are embedded in the tendons of flexor hallucis brevis.

By Deborah Pate, DC, DACBR The first metatarsophalangeal joint includes four bones. The most readily apparent portion of the joint is the articulation between the concave-shaped base of the proximal phalanx and the convex, rounded head of the first metatarsal. The plantar surface includes the two sesamoid bones (fibular or lateral and tibial or medial) and the joint capsule. The joint capsule is reinforced on its plantar aspect by both a fibrocartilagenous plate and the plantar accessory ligament. The flexor hallucis longus and flexor hallucis brevis attach on the plantar aspect, along with the abductor hallucis muscle and the adductor hallucis muscle. The hallux MTP sesamoids are embedded in the tendons of flexor hallucis brevis. tag:mpamedia.com,2008:post-56216 2012-11-18T12:00:32-07:00 2012-11-18T12:00:07-07:00

The use of computed tomography (CT) is increasing exponentially. Providers and patients are not well-informed about the relative latent cancer risks associated with repetitive exposure to ionizing radiation. Conservative estimates indicate that more than 60 million CT examinations are performed annually in the U.S.

By Deborah Pate, DC, DACBR The use of computed tomography (CT) is increasing exponentially. Providers and patients are not well-informed about the relative latent cancer risks associated with repetitive exposure to ionizing radiation. Conservative estimates indicate that more than 60 million CT examinations are performed annually in the U.S. tag:mpamedia.com,2008:post-56177 2012-10-21T12:00:32-07:00 2012-10-21T12:00:07-07:00

In a recent column [June 17, 2012], I discussed history questions aimed at drawing information from patients who are poor historians. I was surprised by the response to the article. I received several contacts via phone, e-mail, Facebook, etc., from doctors with positive comments. I am pleased the article was of help.

By K. Jeffrey Miller, DC, DABCO In a recent column [June 17, 2012], I discussed history questions aimed at drawing information from patients who are poor historians. I was surprised by the response to the article. I received several contacts via phone, e-mail, Facebook, etc., from doctors with positive comments. I am pleased the article was of help. tag:mpamedia.com,2008:post-56175 2012-10-21T12:00:32-07:00 2012-10-21T12:00:07-07:00

What does the word technique mean to a chiropractor? First and foremost, it refers to the methods they use to adjust the spine. But technique goes far beyond that. What words do we use for our diagnosis? We are constrained by the ICD system, which oversimplifies diagnosis. Are we really treating a lumbar strain, or a lumbar dysfunction, or a lumbar degenerative disease? I think that shortchanges what we do. We know most imaging does not correlate well with pain patterns.

By Marc Heller, DC What does the word technique mean to a chiropractor? First and foremost, it refers to the methods they use to adjust the spine. But technique goes far beyond that. What words do we use for our diagnosis? We are constrained by the ICD system, which oversimplifies diagnosis. Are we really treating a lumbar strain, or a lumbar dysfunction, or a lumbar degenerative disease? I think that shortchanges what we do. We know most imaging does not correlate well with pain patterns. tag:mpamedia.com,2008:post-56158 2012-10-07T12:00:32-07:00 2012-10-07T12:00:07-07:00

We routinely evaluate shoulder problems such as rotator-cuff tendinitis, cuff tears, labral tears (including SLAP lesions), instability, etc., with tests that often are considered valid since they are written up in orthopedic texts and journal articles. However, it is important to evaluate those tests as to their true validity. As I quoted in a previous Dynamic Chiropractic article, most orthopedic tests for the shoulder cannot truly isolate a particular structure, since when we use tests that compress or stretch an area, adjacent structures also have to be compressed, stretched or contracted.

By Warren Hammer, MS, DC, DABCO We routinely evaluate shoulder problems such as rotator-cuff tendinitis, cuff tears, labral tears (including SLAP lesions), instability, etc., with tests that often are considered valid since they are written up in orthopedic texts and journal articles. However, it is important to evaluate those tests as to their true validity. As I quoted in a previous Dynamic Chiropractic article, most orthopedic tests for the shoulder cannot truly isolate a particular structure, since when we use tests that compress or stretch an area, adjacent structures also have to be compressed, stretched or contracted. tag:mpamedia.com,2008:post-56131 2012-09-23T12:00:32-07:00 2012-09-23T12:00:07-07:00

A great exam can make a good first impression with new patients. Patients are impressed with doctors who are thorough and detail oriented. They feel like the doctor cares and will get to the bottom of their problem. An accurate exam means accurate diagnosis. Accurate diagnosis means accurate treatment. Accurate treatment increases the odds of a good prognosis.

By K. Jeffrey Miller, DC, DABCO A great exam can make a good first impression with new patients. Patients are impressed with doctors who are thorough and detail oriented. They feel like the doctor cares and will get to the bottom of their problem. An accurate exam means accurate diagnosis. Accurate diagnosis means accurate treatment. Accurate treatment increases the odds of a good prognosis. tag:mpamedia.com,2008:post-55950 2012-06-17T12:00:32-07:00 2012-06-17T12:00:07-07:00

Every doctor has had the opportunity to work with patients who are poor historians; patients who make the history process almost torturous. The nature of their behavior seems to stem from one of four possible etiologies: Some patients are forgetful, some do not have the capacity to remember (dementia, etc.), some don't think certain information is relevant to their current health status, and some simply don't want the doctor to know particular details about their health.

By K. Jeffrey Miller, DC, DABCO Every doctor has had the opportunity to work with patients who are poor historians; patients who make the history process almost torturous. The nature of their behavior seems to stem from one of four possible etiologies: Some patients are forgetful, some do not have the capacity to remember (dementia, etc.), some don't think certain information is relevant to their current health status, and some simply don't want the doctor to know particular details about their health. tag:mpamedia.com,2008:post-55912 2012-05-20T12:00:32-07:00 2012-05-20T12:00:07-07:00

D.D. Palmer, wrote extensively about the concept of tone. According to Palmer: "Life is the expression of tone. In that sentence is the basic principle of Chiropractic. Tone is the normal degree of nerve tension. Tone is expressed in functions by the normal elasticity, activity, strength and excitability of the various organs, as observed in a state of health. Consequently, the cause of disease is any variation of tone – nerves too tense or too slack."

By Christopher Kent, DC, Esq. D.D. Palmer, wrote extensively about the concept of tone. According to Palmer: "Life is the expression of tone. In that sentence is the basic principle of Chiropractic. Tone is the normal degree of nerve tension. Tone is expressed in functions by the normal elasticity, activity, strength and excitability of the various organs, as observed in a state of health. Consequently, the cause of disease is any variation of tone – nerves too tense or too slack." tag:mpamedia.com,2008:post-55897 2012-05-06T12:00:32-07:00 2012-05-06T12:00:07-07:00

It was no less a personage than Thomas Edison who once opined, "Great ideas originate in the muscles." Roll the tape forward some 75 years and one starts to observe an interesting parallel in functional medicine. For it was at this time that applied kinesiologists and others turned to the muscle as an exquisite indicator and adjunct to the nervous system, either indicating or generating changes in efferent or afferent activity. Put in other terms, the movement characteristics, spasms and electrical activity of the muscle became important tools with which to assess pain and motor function.

By Anthony Rosner, PhD, LLD [Hon.], LLC It was no less a personage than Thomas Edison who once opined, "Great ideas originate in the muscles." Roll the tape forward some 75 years and one starts to observe an interesting parallel in functional medicine. For it was at this time that applied kinesiologists and others turned to the muscle as an exquisite indicator and adjunct to the nervous system, either indicating or generating changes in efferent or afferent activity. Put in other terms, the movement characteristics, spasms and electrical activity of the muscle became important tools with which to assess pain and motor function. tag:mpamedia.com,2008:post-55886 2012-06-03T12:00:32-07:00 2012-06-03T12:00:07-07:00

On April 5, 2012, the Third Court of Appeals of Texas issued a 58-page opinion in Cause No. 03-10-673-CV - the Texas Board of Chiropractic Examiners (TBCE) and the Texas Chiropractic Association (TCA) vs. the Texas Medical Association (TMA), the Texas Medical Board (TMB) and the State of Texas. According to an April 6, 2012 communication by the Texas Chiropractic Association, the case presented three questions for the court: 1) Are the two TBCE rules that allow chiropractors to make certain "diagnoses" valid? 2) Can chiropractors perform MUA? 3) Can chiropractors perform needle EMG?

By James Edwards, DC On April 5, 2012, the Third Court of Appeals of Texas issued a 58-page opinion in Cause No. 03-10-673-CV - the Texas Board of Chiropractic Examiners (TBCE) and the Texas Chiropractic Association (TCA) vs. the Texas Medical Association (TMA), the Texas Medical Board (TMB) and the State of Texas. According to an April 6, 2012 communication by the Texas Chiropractic Association, the case presented three questions for the court: 1) Are the two TBCE rules that allow chiropractors to make certain "diagnoses" valid? 2) Can chiropractors perform MUA? 3) Can chiropractors perform needle EMG? tag:mpamedia.com,2008:post-55793 2012-03-12T12:00:32-07:00 2012-03-12T12:00:07-07:00

Objective: To outline conservative chiropractic treatment and rehabilitation of a midshaft clavicle fracture in a male snowboarder. Background: While attempting to "shred" into a turn, the athlete landed on the outer tip of his shoulder. A sideline evaluation diagnosis of clavicle fracture was determined secondary to reported crepitus and mechanism of injury. Post-injury radiographs revealed a midshaft clavicle fracture. Past medical history included a prior fracture to the same clavicle two years earlier.

By Nancy Martin-Molina, DC, QME, MBA, CCSP Objective: To outline conservative chiropractic treatment and rehabilitation of a midshaft clavicle fracture in a male snowboarder. Background: While attempting to "shred" into a turn, the athlete landed on the outer tip of his shoulder. A sideline evaluation diagnosis of clavicle fracture was determined secondary to reported crepitus and mechanism of injury. Post-injury radiographs revealed a midshaft clavicle fracture. Past medical history included a prior fracture to the same clavicle two years earlier. tag:mpamedia.com,2008:post-55777 2012-02-26T12:00:32-07:00 2012-02-26T12:00:07-07:00

Despite its broad width and significant strength, the Achilles tendon is injured with surprising regularity. In a study of 69 military cadets participating in a six-week basic-training program (which included distance running), 10 of the 69 trainees suffered an Achilles tendon overuse injury.

By Thomas Michaud, DC Despite its broad width and significant strength, the Achilles tendon is injured with surprising regularity. In a study of 69 military cadets participating in a six-week basic-training program (which included distance running), 10 of the 69 trainees suffered an Achilles tendon overuse injury. tag:mpamedia.com,2008:post-55773 2012-02-26T12:00:32-07:00 2012-02-26T12:00:07-07:00

I recently read an article in the Journal of Orthopedic and Sports Physical Therapy that discusses an interesting situation we should all be aware of – deep-vein thrombosis (DVT) presenting as a calf strain.1 The case involved a 21-year-old runner who presented with a calf that felt tight and achy. The patient related that he remembered straining his calf four days previously when he lifted 40 pounds over his head while straightening his knees out of a squat position. There was mild edema over the left calf, pain on toe walking, unilateral heel raises and double-leg squatting, and decreased dorsiflexion of 10° on the painful side. Lower extremity pulses were normal.

By Warren Hammer, MS, DC, DABCO I recently read an article in the Journal of Orthopedic and Sports Physical Therapy that discusses an interesting situation we should all be aware of – deep-vein thrombosis (DVT) presenting as a calf strain.1 The case involved a 21-year-old runner who presented with a calf that felt tight and achy. The patient related that he remembered straining his calf four days previously when he lifted 40 pounds over his head while straightening his knees out of a squat position. There was mild edema over the left calf, pain on toe walking, unilateral heel raises and double-leg squatting, and decreased dorsiflexion of 10° on the painful side. Lower extremity pulses were normal. tag:mpamedia.com,2008:post-55724 2012-01-29T12:00:32-07:00 2012-01-29T12:00:07-07:00

The use of manipulation in the management of biomechanical disorders of the spine may now be regarded as a mainstream approach across health care. However, the management of visceral disorders through treatment of the spine remains controversial, and the association of particular spinal regions with specific visceral disorders, a core precept of the meric system, is regarded with considerable scepticism outside of chiropractic.

By Brian Budgell, DC, PhD The use of manipulation in the management of biomechanical disorders of the spine may now be regarded as a mainstream approach across health care. However, the management of visceral disorders through treatment of the spine remains controversial, and the association of particular spinal regions with specific visceral disorders, a core precept of the meric system, is regarded with considerable scepticism outside of chiropractic. tag:mpamedia.com,2008:post-55689 2012-01-01T12:00:32-07:00 2012-01-01T12:00:07-07:00

How often does a patient come in with an MRI showing a herniated or extruded disc who has been told they need surgery? Examination may show minimal weakness or even diminished reflexes. The problem is that often, the patient did not receive a functional examination to determine other possible causations or treatments that might help repair the area without surgery.

By Warren Hammer, MS, DC, DABCO How often does a patient come in with an MRI showing a herniated or extruded disc who has been told they need surgery? Examination may show minimal weakness or even diminished reflexes. The problem is that often, the patient did not receive a functional examination to determine other possible causations or treatments that might help repair the area without surgery. tag:mpamedia.com,2008:post-55587 2011-10-21T12:00:32-07:00 2011-10-21T12:00:07-07:00

Discussion of reflex testing concludes this series on the six primary areas of neurological examination, which also includes mental status, cranial nerves, coordination, and motor and sensory testing. When performed and interpreted correctly, reflex testing provides the examiner with some of the most object evidence that can be obtained in neurological testing. Deep-tendon, pathological and superficial reflexes all supply a wealth of information on localization and identification of upper and lower motor neuron lesions.

By K. Jeffrey Miller, DC, DABCO Discussion of reflex testing concludes this series on the six primary areas of neurological examination, which also includes mental status, cranial nerves, coordination, and motor and sensory testing. When performed and interpreted correctly, reflex testing provides the examiner with some of the most object evidence that can be obtained in neurological testing. Deep-tendon, pathological and superficial reflexes all supply a wealth of information on localization and identification of upper and lower motor neuron lesions. tag:mpamedia.com,2008:post-55514 2011-09-09T12:00:32-07:00 2011-09-09T12:00:07-07:00

There are five primary sensory modalities typically tested in a routine neurological examination. Three of these, vibration, joint position sense and pinprick, are the focus of this discussion. Light touch and temperature are discussed, but not described in detail. Likewise, higher sensory functions such as stereognosis and graphesthesia are not discussed, as they are seldom the reason for presentation in a chiropractic practice.

By K. Jeffrey Miller, DC, DABCO There are five primary sensory modalities typically tested in a routine neurological examination. Three of these, vibration, joint position sense and pinprick, are the focus of this discussion. Light touch and temperature are discussed, but not described in detail. Likewise, higher sensory functions such as stereognosis and graphesthesia are not discussed, as they are seldom the reason for presentation in a chiropractic practice. tag:mpamedia.com,2008:post-55508 2011-08-26T12:00:32-07:00 2011-08-26T12:00:07-07:00

As health care providers, we have been trained to take a thorough history and perform physical, orthopedic and neurological examinations, as well as utilize radiography or MRI when there are indications of serious spinal pathology, to arrive at a specific diagnosis. Traditionally, determining the precise diagnosis has been considered essential in order to determine the appropriate treatment plan. This, of course, is perhaps even more true in allopathic medicine than in chiropractic. Enormous amounts of time and money can be spent on specialized and technologically sophisticated tests that have been integrated into the diagnostic process.

By Malik Slosberg, DC, MS As health care providers, we have been trained to take a thorough history and perform physical, orthopedic and neurological examinations, as well as utilize radiography or MRI when there are indications of serious spinal pathology, to arrive at a specific diagnosis. Traditionally, determining the precise diagnosis has been considered essential in order to determine the appropriate treatment plan. This, of course, is perhaps even more true in allopathic medicine than in chiropractic. Enormous amounts of time and money can be spent on specialized and technologically sophisticated tests that have been integrated into the diagnostic process. tag:mpamedia.com,2008:post-55471 2011-08-12T12:00:32-07:00 2011-08-12T12:00:07-07:00

Testing motor function has several facets. Strength, lower motor function, upper motor function and tone are standard neurological components of motor testing. Some also bring manual muscle testing (reflexive test, applied kinesiology) into this realm, but it has a different purpose and performance, and will not be discussed in this writing.

By K. Jeffrey Miller, DC, DABCO Testing motor function has several facets. Strength, lower motor function, upper motor function and tone are standard neurological components of motor testing. Some also bring manual muscle testing (reflexive test, applied kinesiology) into this realm, but it has a different purpose and performance, and will not be discussed in this writing. tag:mpamedia.com,2008:post-55470 2011-08-12T12:00:32-07:00 2011-08-12T12:00:07-07:00

Say goodbye to cookie-cutter treatment programming - toss it, get rid of it, abandon it and lose it. You get the point. Your patient deserves more. Every person is unique in what they require to get well. Everyone wants to get out of pain. Pain is a very powerful motivator for change. I have yet to meet anyone who actually enjoys being in pain. However, what individuals need to get out of pain can vary greatly. This is where your clinical expertise is the game changer. You also need a "human element" that is critical to long-term success.

By Perry Nickelston, DC, FMS, SFMA Say goodbye to cookie-cutter treatment programming - toss it, get rid of it, abandon it and lose it. You get the point. Your patient deserves more. Every person is unique in what they require to get well. Everyone wants to get out of pain. Pain is a very powerful motivator for change. I have yet to meet anyone who actually enjoys being in pain. However, what individuals need to get out of pain can vary greatly. This is where your clinical expertise is the game changer. You also need a "human element" that is critical to long-term success. tag:mpamedia.com,2008:post-55412 2011-07-01T12:00:32-07:00 2011-07-01T12:00:07-07:00

This concludes our series on patient "M," who entered my office in January hoping that manipulation would provide her some relief. The complaints noted on her intake form included pain in her head, neck, upper back, middle back, lower back, arms and legs. During the history, we discovered she also had fatigue, brain fog, dizziness, burning feet (especially at night), poor exercise tolerance, hair loss and difficulty sleeping.

By G. Douglas Andersen, DC, DACBSP, CCN This concludes our series on patient "M," who entered my office in January hoping that manipulation would provide her some relief. The complaints noted on her intake form included pain in her head, neck, upper back, middle back, lower back, arms and legs. During the history, we discovered she also had fatigue, brain fog, dizziness, burning feet (especially at night), poor exercise tolerance, hair loss and difficulty sleeping. tag:mpamedia.com,2008:post-55399 2011-06-17T12:00:32-07:00 2011-06-17T12:00:07-07:00

With chiropractic backgrounds rooted in motion palpation and functional rehabilitation, we have observed that the upper-thoracic spine may be the most commonly restricted area in the locomotor system. This restriction of multiple segments (C7-T5) is likely related to cervical disc herniations; degenerative changes at the lower cervical spine; shoulder impingement and rotator-cuff pathologies; and low back pain.

By Craig Liebenson, DC and Brett Winchester, DC, FASBE(C), DAAPM, DAAMLP With chiropractic backgrounds rooted in motion palpation and functional rehabilitation, we have observed that the upper-thoracic spine may be the most commonly restricted area in the locomotor system. This restriction of multiple segments (C7-T5) is likely related to cervical disc herniations; degenerative changes at the lower cervical spine; shoulder impingement and rotator-cuff pathologies; and low back pain.