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The title, “Where and what is your DRIVER”, refers to an area of the body where you think is the pain provocator, source of greatest dysfunction, locator of primary deficits, or in general the most common targeted area to intervene to get the most bang for your buck.  Now that is a run on sentence!

You can also call it the queen bee hive or the sweet spot.  Every therapist has one (or more), I want to hear yours!

This post is more open-ended questions & quick thoughts intended to get your feedback. Let’s start from the head and work our way caudally.

CV: The cranio-vertebral segment can be a prevalent source of dysfunction.  A decreased angle can lead to local neck pain, headaches, dizziness & possible caudal/distal complaints. From having too much upper cervical spine extension compressing the myriad of nerve roots exiting here to motor control deficits of anterior musculature, can this segment be the one?

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AA: By far a commonplace of pain provocation, the C1-2 segment can be very unpleasant and misbehaves quite often.  It is the most cephalic source of rotation for the body and mostly agreed upon to be source of cervicogenic headaches.  A regular joint for manipulation by chiropractors and top breakout session with accompanying treatment if trained in SFMA.  The obliquus capitis inferior straddles this joint and can be a hot spot for soft tissue treatment by massage therapists, myofascial trained clinicians and dry needlers.

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CTJ:  The top two choices above are almost always stemming from hypomobility and derangements at this problematic junction zone.  Can be nicknamed the Pembroke Pines of the spine, this multi-level (C7-T3 segments) is a rigid intersection worth addressing.   Surgeons want to avoid it but we certainly have many approaches to this hostile area.

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Scapulae: These girdles work marvelously individually and even together at a mathematically determined ratio with the brachium’s long bone.  Disruption in the firing patterns and postural position can alter how the upper quarter operates and can in turn affect the spine.  We can do so much more than shrug up and retraction down and in to address this area. The Romans thought the bone looked like a trowel, but is this your go-to tool?

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Mid-thoracic spine: The most prominent segment of the spine posteriorly is at T4.  With our ADLs leading more towards a rounded and forward posture, is this level a considerable hazard?  Manual percussion often resonates adversely here and manipulation in this region usually ends with a Kelly Clarkson moment, but in a pain-relieving way.  Manipulation has a powerful effect here, especially due to its close proximity to the autonomic nervous system.

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Thoracic Ring (ribs): Linda-Joy (LJ) Lee may have hit the center of the universe here.  With the rib’s attachments to the spine posteriorly, the sternum anteriorly and a prime seat next to the diaphragm, the claim of treating this to improve optimal trunk and core function may have some substance behind it.  By encompassing a large percentage of the body, is this the ideal treatment zone?

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Thoraco-lumbar junction:  Not a large threat in my opinion but can be the answer if other locations fail to achieve results.  Flared lower ribs and hyper-lordosis could create mayhem at this sector.

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SIJ (innominates): You know this could not be left out!  This is by far the site of the most polarizing opinions by clinicians in all fields.  It will be debated and researched until the sun doesn’t shine anymore. Sources show between 10-25% of the LBP arises from the SIJ, but is it 100% in your clinic?  Should we rely on well-documented provocation tests or is there an existence that just can’t be studied by research?

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Hips: Connecting congruently with the innominates through a deep crater and site of concentric action anteriorly during the first steps of the gait cycle, how can it not get into trouble?  Weakness in the lateral/posterior structures has been demonstrated every month in JOSPT for the last 5 years to be related to just about every condition and controversy continues to exist for tightness in the IT Band and hip flexors.  Is there truth to all this madness?

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Foot/Ankle Complex (FAC):  As soon as the feet hit the floor, dysfunction in the mingled array of bones and tendons that attach to almost every bone has to create dilemmas right?  Are we relying too much on orthotics, inserts and cushion shoes with our modern advances? Is this area becoming a light-weight that can’t handle forces anymore?  Is treating it just a gimmic or is there substantial certainty that this complex is the one?

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So where is your bread and butter intervention that gets maximal results?  Did your work-horse territory make the list above?  I didn’t include much soft tissue areas, what do the myofascial therapists think? Where IS  the underlying problem area? Or, IS THERE ONE? Is is like trying to find a needle in a haystack? Let’s hear (read) your feedback in discussion below.

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  1. I for one think the cuboid is the epicenter of all painful dysfunctions 😉

    Great post Harrison. Good mix of evidence based points with clinical pearls that research hasn’t really agreed with yet. I still find the whole thoracic ring theory to be a little fluffy. It relies so much on minutiae palpatory findings and then correlated those findings to very distal problems at times.

  2. Yes Jesse, I can’t believe I forgot cuboid! I actually saw a DC on youtube awhile back toting this as the key to just about every problem, including systems other than MSK.

    The post may have a tone of being sarcastic in some regards, but overall there are hot spots that we all treat and they work for 80%+.

  3. This is funny and provocative. It’s refreshing to see us P.T.’s having a sense of humor. if there is one source of pain,what might that be? I think asking this open ended question and then letting go of any attachment to what we might see may let us see things in a way that may provide us with a clue of where to look. Being ok with not needing to know, what might we know? If we were to notice how much we really don’t know, absolutely, what might we notice?

    From this space of unknowing, we may be lead to the answer. It’s an interesting way to approach a situation and a client. It’s open ended; it’s nonjudgmental; it’s full of chaos and of all possibilities. Maybe then we’d find it is actually in the cuboid 🙂

    great post

    Ralph Havens
    Bellingham, Wa and worldwide via phone & Skype *

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