Course Notes: The Eclectic Approach to Upper Quarter Evaluation and Treatment

I recently attended this course with my man Erson Religioso III. It was great connecting with him and learning his approach. Check out his stuff on

Overall, I thought it was an excellent course and definitely opened my mind to an approach (i.e. McKenzie) that I was not a huge fan of. I highly recommend taking one of his courses. Here were some of the pearls I got from his course. My thoughts will be italicized.

On Assessments

  • “If you don’t have a system, you are lost in an evaluation.”
  • The SFMA reasons why people get hurt.
    • #1 cause – previous injury.
    • Asymmetry of quality and quantity.
    • Motor control.
    • Stupidity.
    • Just because you clear something once doesn’t mean it has been cleared forever.
    • If one has knee pain and decreased ankle dorsiflexion, check tibial internal rotation.


On Education

On Neuroscience

  • Nerves move like an arm in a sleeve. A tight sleeve wears down myelin which is replaced with ion channels. This is why nerves become sensitive.
    • Also why you must treat the entire nerve container.
    • Abnormal impulse generating site (AIGS)
      • These fire both ways.
      • Not normally at the sight of symptoms.
      • If symptoms are episodic, then it is not centrally maintained.
        • If you skin your knee 10 times in 10 years, you don’t say I have a chronic skinned-knee problem.

On Surgery

  • “Less than 1% of the population needs surgery, yet insurance still covers it.”
  • “Patients who underwent surgery did not see a good PT.” ~Stanley Paris


On Posture

  • “Posture is a reflection of your attitude toward life.” ~ Stanley Paris
  • Posture is a risk factor, not a causative factor.

On Treatments

  • Kinesiotape provides a constant stimulus to the nervous system. May allow for better superficial fascia movement.

On Home Exercise Programs (HEP)

  • “We can only help someone if they can help themselves.”
  • Manual therapy effects last 5-45 minutes. The HEP keeps this longer.
  • “If you walk out of here feeling better, you make it last.”
  • Keep the HEP simple so patients are more likely to do it.
  • Nice cue for cervical retraction: Pretend your chin is on a table and an ugly guy is trying to kiss you.
  • If something stops working, something changed with the exercise. Make sure they are doing it right.

On Manual Therapy

  • Everything we do is neurophysiologic. Otherwise huge range of motion changes in quick timeframe would likely rupture muscle.
  • End range is key to creating rapid change. This is due to increased mechanoreceptor firing. It is easier to get to end range with closing patterns.
  • Posterior to anterior intervertebral motion (PAIVM) at one level moves two adjacent levels above and below. So don’t even think you can be specific.
  • Manual therapy is unplugging and plugging in the router.
  • We cannot change bone position, but we can change how people move.
  • “If I don’t have to cause pain, I won’t.”
  • “I don’t document levels anymore. We cannot be specific.”

On Soft Tissue Mobilization

  • We can only change superficial fascial fibrosis, as it takes 100-200# of force to deform deep fascia 1%.
  • Ultrasound research shows greatest tissue changes occur within 2 minutes.
  • Restrictions are the superficial grit and fibrosis and require quick light strokes with a tool.
  • To change tone use slow, light strokes with a tool.

On McKenzie MDT

  • Stoplight rule
    • Red light: Pain increases and remains worse, then change direction.
    • Yellow light: Pain increases, but does not remain worse. Not hurting, so keep going.
    • Green light: Pain decreases, so continue with direction.
    • HEP performed 10 times per hour to reinforce gains.
    • Classify your patients into two types.
      • Fast responder: insidious onset. Contrary motion and closing pattern is key.
      • Slow responder: Multidirectional ROM limitations. Likely will not make major changes in 6 visit timeframe. These people need tissue to adapt, and work best in mid-range.
      • A slow responding area is usually adjacent to a fast responding area.
      • The disk reducing explanation is not correct with McKenzie, because the end range principle works at joints that do not have a disk.
      • Operator vs. instructor.
        • An operator has magic hands to help the patient.
        • An instructor teaches the patient how to get better on their own.
        • McKenzie is not for pansies.

    1. A closing pattern to my understanding is akin to the closed packed position, where the bones of the joints are at maximum congruency. The joint space is decreased. For example, in the cervical spine, the closing pattern for the zygopophyseal joints would bed extension and sidebending (assuming neutral mechanics).

      1. I see this time of ‘2 minutes’ for soft tissue changes being used a lot, but I can’t seem to find any evidence. I’m doing my dissertation at the moment and this would help really justify a part of my rationale. Can you forward me to any papers?? thank you so much. Karl

        1. Well Karl you’ve stumped me. I’ve searched all the articles that I thought would’ve had it and couldn’t find anything. Blame my youthfulness at the time for not asking for a reference. You may want to ask Erson himself:

          Sorry I could not be of help.

          1. Thank you for looking Zac. I ended up putting in a slightly convoluted argument with multiple references. Hopefully they don’t overly scrutinise the sources at undergrad!