Advanced Methods: Spine (specialisation)
13 de setembro de 2025 18:09
Lesson 1 - Arthrogenic, myofascial and neurodynamic approach
lectureAdv
.Spine1(1)
The ICF is our guide in clinical reasoning:
From all of these components, we need to evaluate which one(s) is the dominant. From there we define treatment goals,
strategy and means and timing, duration and number of sessions.
Range of motion Base Coordination, Posture and Movement Pain, symptoms and Physical
structure control patterns fitness
Articular Tendon Proprioception Peripheral mechanisms Cardiovascular
Muscular Bone Muscle control Central mechanisms Respiratory
Neural Muscles Endurance Matabolic
Muscle control Fascia Strength
Neural Balance
Vascular
Psychological
99% of the patients' first complaint is pain. We need to understand the underlying mechanisms of pain, so we can decide the
best approach. Additionally, we should also remember that the dominant mechanism can change over time.
Neurogenic pain: Umbrella term for nerve involvement.
• Pain in the nerves without structural damage ou with damage (neuropathic pain).
• Usually in systematic problems (IBS and immuno diseases).
Arthrogenic Approach Framework
Arthrogenic muscle inhibition (AMI): AMI occurs when the nervous system reduces voluntary muscle activation around a
joint in response to injury, pain, swelling, or altered proprioception
1) Sensory receptors in the joint, including mechanoreceptors and nociceptors, detect changes such as ligament damage,
cartilage injury, or joint effusion.
2) These receptors send signals to the spinal cord and brain, activating inhibitory interneurons that suppress the motor
neuron pool controlling the surrounding muscles.
3) This reflexive inhibition is presynaptic and ongoing, serving as a protective mechanism to prevent further joint damage
Neurometabolic framework that emphasizes the impact of joint-related dysfunction on muscle activation and recovery. It is
crucial for understanding and treating conditions like AMI (relevant in the context of joint injuries, surgeries, and conditions
like arthritis).
Even though this is widely used, it is not evidence-based. It was created based on expertise.
Courses and notes Page 1
,This is a very useful tool, but only for a limited number of patients.
Clinical clues to decide if the arthrogenic algorithm is appropriate:
1) Provocation of symptoms during passive combined movement testing: Note which directions provockes pain
○ Example: Extension vs. Flexion, combined with Side bending + Rotation
2) Type of mechanical pain: There are two articular dysfunction patterns. They guide the direction of our
mobilisation/manipulation
• Convergence pattern: Pain in compression of the facet joints' surfaces (closing of the facet joints)
○ Extension + lateral bending (IL) + rotation (CL)
○ Convergent patterns is more connected with the acute phase than the divergence pattern (in the later phases)
• Divergence pattern: Pain in stretch of the facet joints' capsule (opening of the facet joints)
○ Flexion + lateral bending (CL) + rotation (IL)
3) Restricted intervertebral movement tests: Test the movement of each lumbar level with segmental mobility tests and
look for hypomobility or a painful, stiff segment that matches the level suggested by your provocation tests.
If a level is both painful on the combined movement and restricted on passive intervertebral testing, that level becomes
your main treatment target.
The arthrogenic algorithm is used for lumbar spine mobilization when:
• Predominantly mechanical nociceptive pain: related to movement, not neural or central mechanisms
• Probably arising from the zygapophyseal joints
In this situation, the patients are likely to respond to mobilization/ manipulation because of good outcomes when the
problem comes from the facet joint.
Arthrogenic Approach: Clinical Framework
Courses and notes Page 2
, 1- Rule out red flags
2- Distinguish convergence and divergence patterns
a. Test combined movements
b. Test intervertebral movements
3- Define treatment goal
○ Convergence pattern: pain relief, (restore function) -> Distraction technique
○ Divergence pattern: restore function, (pain relief) -> Rotation technique
4- Define treatment techniques: Classify phases based on timeline. In manipulations and mobilisations we need to have a
very stabilised part of the body so that we can mobilise the other part
○ Distraction techniques
○ Rotation techniques
○ Side bending technique
What actually happens in mobilisation?
Scientific evidence does not support segmental motion or changes in stiffness. It suggests that spinal mobilisations cause
neurophysiological effects that result in hypoalgesia, sympathoexcitation and improved muscle function.
Myofascial Approach Framework
Myofascial pain syndrome (MPS): Myalgic condition in which muscle- and musculotendinous pain are the primary symptoms.
Myofascial trigger points (MTrPs) are the hallmark characteristic of MPS and feature motor, sensory and autonomic
components. MTrP is a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut
band
• The taut band is a group of contracted fibers, readily palpable, and tender at the region of greatest hardness
Medical imaging shown that the myofascial trigger points are real physiological phenomens, but the underlying mechanisms
are not well known.
• Active trigger point: Symptom producing MTrP and can trigger local or referred pain or other paraesthesiae
• Latent trigger point: Does not trigger pain without being stimulated
Courses and notes Page 3
, • Latent trigger point: Does not trigger pain without being stimulated
Motor aspects of active and latent MTrPs Disturbed motor function
Muscle weakness as a result of motor inhibition
Muscle stiffness
Restricted range of motion (ROM)
Sensory aspects of active and latent MTrPs Local tenderness
Referral of pain to a distant site
Peripheral and central sensitization
Types of trigger points and their referal areas
What does the evidence say regarding myofascial trigger points?
This systematic review showed that active and latent MTrPs can be present in different spinal disorders, but these findings are
based on low-quality evidence.
Based on this systematic review, MTrPs are a prevalent clinical entity in people with neck pain. Besides neck, evidence to
Courses and notes Page 4
13 de setembro de 2025 18:09
Lesson 1 - Arthrogenic, myofascial and neurodynamic approach
lectureAdv
.Spine1(1)
The ICF is our guide in clinical reasoning:
From all of these components, we need to evaluate which one(s) is the dominant. From there we define treatment goals,
strategy and means and timing, duration and number of sessions.
Range of motion Base Coordination, Posture and Movement Pain, symptoms and Physical
structure control patterns fitness
Articular Tendon Proprioception Peripheral mechanisms Cardiovascular
Muscular Bone Muscle control Central mechanisms Respiratory
Neural Muscles Endurance Matabolic
Muscle control Fascia Strength
Neural Balance
Vascular
Psychological
99% of the patients' first complaint is pain. We need to understand the underlying mechanisms of pain, so we can decide the
best approach. Additionally, we should also remember that the dominant mechanism can change over time.
Neurogenic pain: Umbrella term for nerve involvement.
• Pain in the nerves without structural damage ou with damage (neuropathic pain).
• Usually in systematic problems (IBS and immuno diseases).
Arthrogenic Approach Framework
Arthrogenic muscle inhibition (AMI): AMI occurs when the nervous system reduces voluntary muscle activation around a
joint in response to injury, pain, swelling, or altered proprioception
1) Sensory receptors in the joint, including mechanoreceptors and nociceptors, detect changes such as ligament damage,
cartilage injury, or joint effusion.
2) These receptors send signals to the spinal cord and brain, activating inhibitory interneurons that suppress the motor
neuron pool controlling the surrounding muscles.
3) This reflexive inhibition is presynaptic and ongoing, serving as a protective mechanism to prevent further joint damage
Neurometabolic framework that emphasizes the impact of joint-related dysfunction on muscle activation and recovery. It is
crucial for understanding and treating conditions like AMI (relevant in the context of joint injuries, surgeries, and conditions
like arthritis).
Even though this is widely used, it is not evidence-based. It was created based on expertise.
Courses and notes Page 1
,This is a very useful tool, but only for a limited number of patients.
Clinical clues to decide if the arthrogenic algorithm is appropriate:
1) Provocation of symptoms during passive combined movement testing: Note which directions provockes pain
○ Example: Extension vs. Flexion, combined with Side bending + Rotation
2) Type of mechanical pain: There are two articular dysfunction patterns. They guide the direction of our
mobilisation/manipulation
• Convergence pattern: Pain in compression of the facet joints' surfaces (closing of the facet joints)
○ Extension + lateral bending (IL) + rotation (CL)
○ Convergent patterns is more connected with the acute phase than the divergence pattern (in the later phases)
• Divergence pattern: Pain in stretch of the facet joints' capsule (opening of the facet joints)
○ Flexion + lateral bending (CL) + rotation (IL)
3) Restricted intervertebral movement tests: Test the movement of each lumbar level with segmental mobility tests and
look for hypomobility or a painful, stiff segment that matches the level suggested by your provocation tests.
If a level is both painful on the combined movement and restricted on passive intervertebral testing, that level becomes
your main treatment target.
The arthrogenic algorithm is used for lumbar spine mobilization when:
• Predominantly mechanical nociceptive pain: related to movement, not neural or central mechanisms
• Probably arising from the zygapophyseal joints
In this situation, the patients are likely to respond to mobilization/ manipulation because of good outcomes when the
problem comes from the facet joint.
Arthrogenic Approach: Clinical Framework
Courses and notes Page 2
, 1- Rule out red flags
2- Distinguish convergence and divergence patterns
a. Test combined movements
b. Test intervertebral movements
3- Define treatment goal
○ Convergence pattern: pain relief, (restore function) -> Distraction technique
○ Divergence pattern: restore function, (pain relief) -> Rotation technique
4- Define treatment techniques: Classify phases based on timeline. In manipulations and mobilisations we need to have a
very stabilised part of the body so that we can mobilise the other part
○ Distraction techniques
○ Rotation techniques
○ Side bending technique
What actually happens in mobilisation?
Scientific evidence does not support segmental motion or changes in stiffness. It suggests that spinal mobilisations cause
neurophysiological effects that result in hypoalgesia, sympathoexcitation and improved muscle function.
Myofascial Approach Framework
Myofascial pain syndrome (MPS): Myalgic condition in which muscle- and musculotendinous pain are the primary symptoms.
Myofascial trigger points (MTrPs) are the hallmark characteristic of MPS and feature motor, sensory and autonomic
components. MTrP is a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut
band
• The taut band is a group of contracted fibers, readily palpable, and tender at the region of greatest hardness
Medical imaging shown that the myofascial trigger points are real physiological phenomens, but the underlying mechanisms
are not well known.
• Active trigger point: Symptom producing MTrP and can trigger local or referred pain or other paraesthesiae
• Latent trigger point: Does not trigger pain without being stimulated
Courses and notes Page 3
, • Latent trigger point: Does not trigger pain without being stimulated
Motor aspects of active and latent MTrPs Disturbed motor function
Muscle weakness as a result of motor inhibition
Muscle stiffness
Restricted range of motion (ROM)
Sensory aspects of active and latent MTrPs Local tenderness
Referral of pain to a distant site
Peripheral and central sensitization
Types of trigger points and their referal areas
What does the evidence say regarding myofascial trigger points?
This systematic review showed that active and latent MTrPs can be present in different spinal disorders, but these findings are
based on low-quality evidence.
Based on this systematic review, MTrPs are a prevalent clinical entity in people with neck pain. Besides neck, evidence to
Courses and notes Page 4
