INTRO LUMBAR SPINE I

© The Manual Therapy Institute PLLC 1998-2018

CONTENT

Anatomy 3

Biomechanics and arthrokinematics 9

Evaluation lumbar spine 11

Segmental mobility testing 22

Joint mobilizations 30

AnatomyThe lumbar vertebrae

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Vertebral bodyThe vertebral body is box shaped, with flat top and bottom surfaces and slightly concave anterior and lateral surfaces. Viewed from above the body is kidney shaped. The body is the weight-bearing portion of the vertebra. Even without other supporting structures, 2 articulated vertebrae could withstand great longitudinal loads. The body is made up of a cortical bone shell surrounding a cancellous cavity. If the structure was solid bone it would be strong, but it would not be well suited for dynamic loading. It would not be able to absorb and dissipate sudden loads, which then could result in fracture. Therefore the core of the body has vertical struts, which can sustain larger vertical loads. Those struts are connected by horizontal crossbeams (trabeculae), preventing them from deforming and collapsing. It is the transfer of load from vertical pressure to transverse tension that gives the vertebra its resilience. It is also very light and it uses a minimum amount of materials: the minimum principle, optimum design.

The pediclesAttached to the back of the vertebral body is an arch of bone, the neural arch, so called because it surrounds the neural elements that pass through the vertebral column.Projected from the back are the pedicles, which attach to the upper part of the body. All forces sustained by any of the posterior elements are transferred through the pedicles to the vertebral bodies. They are very well designed to withstand those forces. In cross section they are cylindrical shaped with thick walls, which resists bending in any direction. In accordance with engineering principles, a beam when bent resists deformation with its outer surfaces. Towards the center, forces reduce to zero. Therefore there is no need for bone in the center of the pedicle, which explains why the pedicle is hollow but has thick walls of bone.

The laminaeProjected from each pedicle towards the middle is a sheet of bone called the lamina (“leaf”). The 2 laminae fuse with one another at the mid line. Traditionally, the function of the lamina was thought to be a protective one, covering the spinal cord. However, patients with a laminectomy do not suffer any ill effects to their nervous system. It does play a crucial role in providing stability. Forces that act on the spinous and articular processes are transmitted to the laminae. The part of the lamina between the superior and inferior articular process is called the pars interarticularis. It lies at the junction of the lamina and pedicle and is therefore subjected to considerable amounts of stress. To withstand these forces, the cortical bone is usually thicker than in the rest of the lamina.

The facet joints

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Each vertebra has 4 articular processes, 2 superior and 2 inferior. On the posterior edge of each of the superior articular processes is a small bump, called the mamillary processes. This functions as an attachment for lumbar musculature.The inferior articular process of the superior vertebra and the superior articular process from the inferior vertebra form the facet joint. The articular facets are ovoid in shape and are some 16 mm in height and 14 mm in width. Generally the joints are planar but significant variations do exist.

The facet joints are the principle guiding and restraining mechanism of the segment. They protect the disc from excessive strain and keep the segment stable. A fibrous capsule surrounds the joints. It is thick dorsally and reinforced by deep fibres of the multifidus. Anteriorly, the capsule is replaced entirely by the ligamentum flavum.The joints have intra articular meniscoid structures that play an important role in protecting the joint and keeping the joint surfaces lubricated during normal movement.The spinous-, mamillary-, accessory- and transverse processes function as attachments for the lumbar musculature and ligaments.

Ligaments of the lumbar spine

Anterior longitudinal ligamentPrimarily attached to the anterior margins of the lumbar vertebral bodies. The space between the ligament and the bone is filled with fatty tissue, blood vessels and nerves. The ligament is only loosely attached to the front of the disc. It primarily resists extension.

Posterior longitudinal ligamentIn the lumbar spine it forms a narrow band over the backs of the vertebral bodies, but expands laterally over the backs of the discs to give it a saw-toothed appearance. It primarily resists flexion.

Ligamentum flavumShort but thick ligament that connects the laminae of consecutive vertebrae. It consists of 80% elastin and 20 % collagen. The elastic fibers give the ligament it’s yellow color, hence its name, ligamentum flavum (= yellow). As an elastic ligament it differs from other ligaments in the spine. The ligament pre stresses the disc, but the biological significance remains obscure. It does not contribute to producing extension. Its main function is to prevent flexion. Due to its elastic properties the ligament does not buckle when the spine is extended. A collagen ligament would buckle, thereby possibly impinging on the spinal cord. Therefore, by endowing the ligamentum flavum with elastic tissue, the risk of nerve root compromise is reduced.

Interspinous ligament

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Connects adjacent spinous processes. Anteriorly, it forms a paired structure, the ligament on each side being separated by a mid line cavity filled with fat. The fibers of the ligament are poorly disposed to resist separation of the spinous processes as they run almost perpendicular to the direction of separation of the spinous processes. Therefore, contrary to traditional wisdom, the interspinous ligament can offer little resistance to flexion. Panjabi and White state that in 75% of adults there is “cavitation where the ligaments are normally located”. The interspinous ligament can be expected to make very little contribution to clinical stability of the lumbar spine.

Supraspinous ligamentIt lies in the mid line and runs posterior to the posterior edges of the spinous processes, to which it is attached. The ligament is well developed only in the upper lumbar region. It terminates usually at L3 (22%) or L 4 (75%) and is regularly lacking at L5-S1. The ligament consists mainly of tendinous fibers derived from the back muscles and is therefore not truly a ligament. It can be seen as part of the deep layer of fascia that anchors the skin to the thoracolumbar fascia. It affords little resistance to separation of the spinous processes. However, according to Panjabi and White, the supraspinous ligament appears to play a major role in providing lumbar spine stability

Iliolumbar ligamentOn each side of the vertebra they connect the transverse processes of the 5th lumbar vertebra to the ilium. They extend from the tip of the TP to an area on the anteromedial surface of the ilium and the inner lip of the iliac crest. Kapandji also recognizes a superior part that runs from the tip of the L4 TP to the iliac crest. However, the existence of the ligament has been questioned. One study found it to be present only in adults, while in children it was represented by a bundle of muscle. The interpretation was that this muscle is gradually replaced by ligamentous tissue. Regardless of what its structure may or may not be, in the adult it forms a strong bond between L5 and the ilium. As a whole it prevents forward sliding of L5. It also resists sidebending, and to a lesser degree twisting, forward bending and backward bending of L5.

Intertransverse ligamentConsist of sheets of connective tissue extending from the upper border of one transverse process to the lower border of the transverse process above. Their appearance is much like that of a membrane. Bogduk calls it a false ligament. Rather than being a true ligament, they form part of a complex fascial system. They form a septum that divides the anterior muscles of the lumbar spine from the posterior muscles.

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Schematic representation of the ligamentous anatomy of the lumbar vertebra

1. Supraspinous ligament2. Interspinous ligament3. Yellow ligament4. Facet joint capsule5. Intertransverse ligament6. Posterior longitudinal ligament7. Annulus fibrosis8. Anterior longitudinal ligament

Lumbar musculature

Psoas majorArises from the anterolateral aspect of the lumbar spine and inserts into the lesser trochanter of the femur. At each segmental level from T12 to L5 it is attached to the anterior surface of the TP, to the disc and to the margins of the vertebral bodies adjacent to the disc. Its influence on lumbar flexion and extension appears to be fairly minor according to Bogduk. Its principle action is flexion of the hip. It does have the potential to exert massive compression loads on the lower lumbar discs.

Quadratus lumborumA wide, rectangular muscle that covers the lateral TP’s of L1-L4 and extends laterally a few centimeters beyond the tips of the TP’s. The majority of the fibers are connected to the 12th rib. The fibers insert on the iliac crest. One of the functions of the muscle is said to be to fixate the 12th rib during inspiration. The other function is to contribute to sidebending of the lumbar spine. Its function in regards to functional stabilization is still uncertain.

Interspinales

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Short, paired muscles that lie on either side of the interspinous ligament and connect the SP of adjacent lumbar vertebrae. Although disposed to produce extension, the muscles are very small and can only develop a small amount of force.

Intertransversarii lateralisConsists of 2 parts, ventral and dorsal. The ventral part connects consecutive TP’s, the dorsal part connects an accessory process to a TP below .The function of these muscles has never been determined experimentally.

Intertransversarii medialisArise from the accessory process, mamillary process and insert into the superior aspect of the mamillary process of the vertebra below. Produce sidebending and extension. Again, the muscles are very small and not likely to contribute much force. More than likely, the intertransversarii and the interspinales act as large proprioceptive transducers. Their value lies in the amount of muscle spindles they contain, not the amount of force they can produce. All uni-segmental muscles of the spine have 2 to 6 times the density of muscle spindles then the long back muscles. Lying close to the spinal column, they could monitor movement and provide feedback.

MultifidusThe largest and most medial of the back muscles. The shortest fascicles are the laminar fibers, which arise from the dorsal surface of a lamina and inserts into the mamillary process of the vertebra 2 levels below. The bulk of the muscle consists of large fascicles arising from the SP’s. They are arranged in 5 overlapping groups such that each vertebra gives rise to one of these groups. At each level, several fascicles arise by way of a common tendon from the spinous process and diverge caudally to assume separate attachments to the mamillary process, the iliac crest and the sacrum. Some of the deeper fibers attach to the facet joint capsule, which allows the multifidus to protect the joint capsule from being caught inside the joint during movement. The muscle is well suited to produce extension, and to a lesser degree rotation. According to Bogduk, the main role of the multifidus is not to produce rotation, but to oppose the flexion effect of the abdominal muscles as they produce rotation.

Erector spinaeLies lateral to the multifidus and forms the prominent dorsolateral contour of the back muscles in the lumbar region. It consists of 2 muscles: the longissimus thoracis and the iliocostalis lumborum. Each of those muscles has 2 components: a lumbar and a thoracic.

The fascicles from the longissimus thoracis pars lumborum arise from the accessory process and the dorsal surface of the TP and insert into the medial aspect of the PSIS. Acting unilaterally, the muscle will produce sidebending; acting bilaterally the muscle will produce extension.

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The iliocostalis lumborum pars lumborum consists of 4 overlying fascicles arising from L1-L4. Each fascicle arises from the tip of the TP and from the thoracolumbar fascia 2-3 cm lateral to the TP. They insert on the iliac crest. Contracting unilaterally, they produce side bending. They are also the only intrinsic muscles of the lumbar spine reasonably disposed to produce rotation.Through these muscles the vertebrae are firmly anchored to the ilium.

The fibers of the longissimus thoracis pars thoracis consist of 12 pairs of fascicles arising from the ribs and TP’s of T1-T12. Each has a muscle belly 7 cm long. Caudally the tendons join in the erector spinae aponeurosis together with the tendons of the iliocostalis lumborum pars thoracis. This is a broad sheet of tendinous fibers attached to the ilium, sacrum and the SP’s of lumbar spine. When contracting bilaterally, it acts indirectly on the lumbar spine and uses the erector spinae aponeurosis to produce an increase in lumbar lordosis.

The fascicles of the iliocostalis lumborum pars thoracis arise from the rib angle of the lower 7 ribs via ribbon like tendon, 10 cm long. It then forms an eight cm muscle belly, after which it continues as a tendon, contributing to the erector spinae aponeurosis. It inserts caudally to the ilium and the sacrum. They have no attachments to the lumbar vertebrae. They span the L spine. If they act bilaterally they cause a bowstring effect, causing an increase in lumbar lordosis.

Thoracolumbar fasciaConsists of 3 layers of fascia that envelop the muscles of the lumbar spine. It arises from the spinous processes and the 3 layers blend together along the lateral border of the iliocostalis lumborum. This union of the 3 layers is quite dense and is called the lateral raphe. It forms a retinaculum over the back muscles. The fascia covers the back muscles, preventing their displacement dorsally. Traditionally its function was thought to be as an attachment for the transverse abdominis and the internal oblique muscles. However, it appears to play an important role in providing stability for the low back. The deep layers of the fascia appear like alar ligaments, anchoring their spinous processes to the ilia.

Reference1. Bogduk, N. Clinical Anatomy of the Lumbar Spine and Sacrum, 4th edition. New York,

USA. Elsevier Churchill Livingstone. 20052. Williams P, ed. Gray’s Anatomy, 38th edition. New York, USA. Churchill Livingstone.

1999

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Biomechanics and Arthrokinematics

The superior articular facet faces medial and posterior. The inferior articular facet faces lateral and anterior. The orientation of the lumbar facet joints significantly inhibits the amount of rotation available in the lumbar spine. The center of rotation does not coincide with the center of the vertebral body. This subjects the disc to substantial shear forces during rotation, thereby limiting the available amount of motion.

Lumbar Spine Range of Motion Reported ROM in the literature is highly variable throughout the various regions of the spine. This reflects differences in research design and differences resulting from gender, age, and activity level of the subjects. Data also vary for active and passive movements, means used to stabilize the subject and the tools used to measure the motion. Typical values are listed below:

Flexion 40-50 degrees

Extension 15-20 degrees

Rotation 5-10 degrees

Sidebending 20 degrees

The predominance of sagittal plane motion is largely a result of the prevailing sagittal plane orientation of the facet surfaces of the lumbar facet joints.

The degree of flexion and extension of the lumbar spine significantly affects the diameter of each intervertebral foramen. Relative to a neutral position, full flexion increases the diameter of the intervertebral foramen by 19%. Full extension reduces the diameter of the intervertebral foramen by 11%.

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Segmental range of motion

Flexion Extension Sidebending RotationT12-L1 5 4 3 4

L1-2 5 4 3 4

L2-3 6 5 4 3

L3-4 7 5 5 2

L4-5 7 7 4 2

L5-S1 6 6 2 2

Arthrokinematics

Flexion Both superior articular surfaces glide up and forward on the inferior articular surfaces

Extension Both superior articular surfaces glide down and back

Rotation The superior articular surface glides down and back on the side to which rotation occurs, and up and forward on the oppositeside. On right rotation, the left superior facet compresses against the left inferior facet. Simultaneously, the right superior facet distracts slightly from the right inferior facet.

Sidebending The superior articular surface glides down and back on the side to which sidebending occurs, and up and forward on the opposite side

CouplingTwo or more individual motions are coupled when one motion is always accompanied by another motion. This phenomenon is due to the geometry of the individual vertebrae, the connecting vertebrae and discs, as well as the curvature of the spine. According to Panjabi and White, sidebending is thought to be coupled with rotation to the opposite side in the lumbar spine. However, keep in mind that evidence exists that lumbar spine coupling has questionable directional predictability. This means that coupling characteristics should be used very cautiously in diagnostic- and treatment procedures.

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Points to remember:1. All motions of a segment are defined by motion of the upper vertebra on the

lower vertebra.2. Rotation is to the side the anterior aspect of the vertebra is facing.

Reference1. White A and Panjabi M. Clinical Biomechanics of the Spine, 2nd edition. Philadelphia,

USA. J.B. Lippincott Company. 19902. Legaspi O, Edmond SL. Does the evidence support the existence of lumbar spine

couple motion? A critical review of the literature. J Orthop Sport Phys Ther. 2007;37:169-178.

3. Neumann D. Kiniesiology of the Musculoskeletal system, 2nd edition. St Louis USA. Mosby Elsevier. 2010

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Subjective Evaluation

Injury mechanism

Is patient improving, worsening or staying the same

What aggravates/relieves the pain. Ask the effects of walking, sitting, standing

Increase in pain with coughing, sneezing

Any change in pain with transitional movements

Temporal pattern of pain: is it worse in the morning, evening, as the day goes on?

Night pain

Sleeping position

Past medical history

Medication

Occupation

Leisure activities

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Objective Evaluation

Structural assessmentLook for what stands out. Don’t get side tracked by minimal findings like a slightly elevated shoulder (unless it’s really elevated of course). Try to note what is significant given the patient’s complaint.

From behind: Scars Scoliosis Muscle tone Palpate iliac crest, PSIS, sacral sulcus, greater trochanter Knee crease Palpate fibula head

From the front: Scoliosis Head position Scars Palpate ASIS

From the side: Spinal A-P curves Forward head Step deformity lumbar spine

Cardinal plane movementsMotions tested: sidebending, rotation, extension and flexion

Purpose 1 To establish a pattern of pain and limitation2 To estimate range3 To establish a baseline for improvement

Look for differences of movement and patient’s willingness to do the movement.

Most painful movement is done last. In the lumbar spine it is a good idea to start with either sidebending or rotation. Try not to get residual pain carry over.

Parameters for assessing active motion: Total range Symmetry of movement Quality of movement Deviations

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Pain (onset, distribution, painful arc) Paresthesia Other considerations such as sex, age and body type

Patterns of pain and limitation

Full capsular patternSymmetrical limitation and pain in rotation and sidebending, with gross restriction of extension. Flexion is relatively unaffected.Indicative of arthritic changes in the spine, or significant inflammation.

Articular pattern1 Opening restriction: the facet joint on one side cannot glide up and forward.

2 Closing restriction: the facet on one side cannot glide down and back.

3 Facet impingement: restriction in extension, sidebending and rotation to the

opposite side

Discogenic patternUsually flexion worsens the signs and symptoms. In severe cases, both flexion and extension worsen signs and symptoms. May be asymmetrically limited and painful in sidebending/rotation if disc lesion is posterolateral and affects a nerve root.

Muscular patternSidebending is painful and restricted to opposite side of pain. Rotation may be painful bilaterally, but less affected than sidebending. Flexion increases pain unilaterally on affected side, but does not worsen. Resisted movements with stretch more painful than resisted movements in neutral.

Repeated movements Assess ROM/pain with repetition. Increasing pain vs. worsening pain. Check for worsening/improving status vs. increasing/decreasing status. Only test when indicated.

Special testing

Spring testing

Compression

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Distraction

Quadrant testing

Palpation

For muscle soreness and tenderness. For tissue texture abnormalities. Concentrate on localizing tenderness to specific structure based on

examination findings. Try to determine level involved. Palpation is done to define, not to find! So save it for last in your evaluation.

Temperature

Tissue texture abnormalities

Lumbosacral junction

Mamillary processes1 thumbs width lateral to the corresponding interspinous space.

Transverse processes

Parallel to the superior edge of the spinous processes, 2 thumb widths laterally.

Alternate: use index finger and thumb, move up and down the spine just laterally from the transverse processes.

Lumbar cutaneous innervated areas

L 1 Inguinal regionL 2 Middle anterior thighL 3 Medial aspect of the kneeL 4 Medial lower leg and ankleL 5 Between first and second toesS 1 Lateral border of footS 2 Popliteal space

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S 3 - 4 Saddle region, perianal region

Lumbar myotomes

Level Resisted movement MuscleL 2 Hip flexion IliopsoasL 3 Knee extension QuadricepsL 4 Ankle dorsiflexion Tibialis anteriorL 5 Extension great toe Extensor hallucis longusS 1 Ankle plantarflexion GastrocnemiusS 2 Knee flexion Hamstrings

Lumbar reflexesPatellar tendon reflex L 3 - 4

Achilles tendon reflex S 1

Babinski reflexNormal response: extension of the foot, flexion of the toes. If the big toe extends, might be indicative of upper motor neuron lesion.

Clonus

Lumbar root syndromes

L 3A. Pain distribution: greater trochanter, distal anterior thigh, medial side of knee.B. Cutaneous innervation: trochanter area, distal anterior thigh, medial side of knee.C. Reflex: PatellarE. Myotome: Quadriceps, Psoas major

L 4A. Pain distribution: upper lateral gluteal region, lateral side of knee, anterior leg

area, medial foot area.B. Cutaneous innervation: Lateral side of knee, anterior medial leg, medial foot areaC. Reflex: PatellarD. Myotome: Quadriceps, tibialis anterior.

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L 5A. Pain distribution: Lateral gluteal region, posterior lateral thigh, lateral leg area,

anterior foot and first toe.B. Cutaneous innervation: Lateral leg, anterior foot area, first and second toesC. Reflex: noneD. Myotome: Extensor hallucis longus, gluteus medius

S 1A. Pain distribution: Lateral gluteal region, medial posterior thigh, lateral leg area,

heel, lateral foot areas, third, fourth, and fifth toes.B. Cutaneous innervation: lateral foot area, third - fifth toes.C. Reflex: AchillesD. Myotome: Peronei, gastrocnemius

S 2 - 3 – 4A. Level: Medial / central prolapse in lumbar regionB. Pain distribution: posterior thigh and leg, perineumC. Cutaneous innervation: sameD. Reflex: noneE. Myotome: Bladder / rectum

Neural tissue tension testing

Slump test

Straight leg raise

Modified slump test for femoral nerve

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Difficulties with interpretation of the straight leg raising test

MethodPatient lies supine. Trunk and hips should be in neutral. Examiner places 1 hand under heel and the other above the knee. The leg is lifted perpendicular, while preventing flexion of the knee. The leg should be lifted as a solid lever moving at a fixed point in the hip joint. Range, symptom response and resistance encountered are noted. These responses are then compared to the SLR of the other leg, and to what is considered normal.

Normal responseThis varies widely. A degree measurement by itself is of little clinical use. It must be interpreted along with the symptom response, the SLR range of the other leg and the overall patient presentation. In most people, tension testing causes some discomfort. There will be normal responses, either resistance from tight tissues, a pain response, or both. The 3 main symptom areas in normals were posterior thigh, posterior knee and posterior calf into the foot.

Positive response When the test reproduces the patient’s symptoms. When the test response can be altered by movement of distant body parts

(passive neck flexion, ankle extension, hip rotation). When there are differences in the test from the left side to the right side and

from what is known to be normal. . Positive signs of increased root tension on SLR point either to a local reactive state involving the root or to a lesion that mechanically compromises the root. The difficulty in interpretation lies in the fact that SLR itself induces stretching in the tissues of the back of the thigh, buttock and lumbar region, as well as lengthening of the spinal canal. Thus pain may be elicited in any of these tissues that is the site of primary pain. The test places force on surrounding interfacing structures as well, which can lead to a positive response if they are affected. However, for the test to be a true indicator that the nerve root is the structure responsible for the reproduction of the symptoms, alteration of symptoms by adding/subtracting a distal component is crucial.

References

1. Breig A, Troup J. (1979) Biomechanical considerations in the Straight Leg Raising Test. Spine. 1979: 4(3)

2. Urban L. (1981) The straight leg raising test: A review. JOSPT.1981; 2(3).

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Manual muscle strength testing

Posterior gluteus mediusPt in sidelying. Abduct the leg, flex the hip, externally rotate the foot. First of all they have to be able to maintain the external rotation. If they cannot do this, the test is over. If they can, you try to push the leg down and forward, while the patient resists. Do not allow the pelvic girdle to roll backwards.

Hip external rotation

Prone Supine

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IliopsoasPt supine. Uninvolved leg flexed. Abduct the leg 45 degrees, flex 45 degrees, externally rotate the leg. Stabilize the hip at the opposite ASIS. Push the leg down and out, while the patient resists.

Gluteus maximusPt prone. Flex the knee. Therapist puts his hand on the thigh, and pushes down while the patient resists.

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Trunk muscle strength/motorcontrolThe following three tests are more designed to test for muscle recruitment of the trunk musculature, then just straight up strength testing.

Bent knee fall outPt supine. Bend the knee, then in a controlled fashion, drop the knee to the outside. If the opposite hip moves more than 1 cm in the first 50% of the bent knee fall out, the test is considered to be positive

MarchingPt supine. Bend both knees. Have patient lift the left leg, put it back down, and then do the same with the right leg. You need to look for proper hip low back disassociation i.e. the ability to move the hip w/o getting the low back involved. If you see the hip drop the moment they lift the leg, the test is considered to be positive.

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Alternate hip extensionPt on all 4’s. It is very helpful to put a stick on the back, as it exaggerates any deficiencies the patient might have (so it is easier to detect). Have patient extend on leg, put it back, then do the same with the opposite leg. Look for proper hip low back disassociation. If the hip drops down as the patient extends the leg, the test is considered to be positive.

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Segmental Mobility Testing

Divided up in PPIVM’s and PAIVM’sPPIVM Passive Physiological Intervertebral MotionPAIVM Passive Accessory Intervertebral Motion

Finger placement and normal findings for the lumbar spine

Palpation Normal FindingsFlexion Between spinoous processes Separation of spinous

processesExtension Between spinous processes Approximation of spinous

processesSidebending

Lateral to interspinous space, on same side to whichsidebending occurs

Motion between SP’s of segment being tested

Rotation Lateral to interspinous space, on opposite side to which rotation occurs (if rotation is cranial to caudal)

SP of upper vertebra bumps against palpating finger (if rotation is cranial to caudal)

Grading is based on:

1. Expected mobility of segment2. Comparison to segments above and below3. Comparing right and left motions to each other4. Consider age, sex and body type

FlexionPatient sidelying. Flex both hips until you feel the gapping in the interspinous space.

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ExtensionPatient sidelying. Start with less than 70 degrees of hip flexion, or you will flex the lumbar spine. Patient’s knees positioned between therapist ASIS and upper femur. To lock up the hip joint, give a little shear force along the long axis of the femur. Then extend the legs until you feel the approximation of the spinous processes.

Sidebending in sidelyingPatient sidelying. Flex hips and knees to 90/90. Bring feet up to sidebend the spine. Palpate lateral to the interspinous space and feel for the spinous processes to bump against your finger.

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Sidebending PronePatient prone. Thumb of cranial hand lateral to interspinous space. Flex knee to 90 degrees. Caudal hand grabs knee and abducts the leg. This creates caudocranial sidebending. Palpate for movement in the interspinous space.

Rotation in sidelyingPatient sidelying. The palpating finger of the caudal hand is placed laterally between the 2 spinous processes of the segment to be tested. The remaining part of the hand is placed to provide stabilization caudal to the segment on the dorsal surface of the pelvis. The cranial forearm is placed on the ventral and lateral surface of the lower ribcage. The fingers are placed laterally to the spinous processes. The cranial arm then rotates the spine.

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Rotation in pronePatient prone. Index finger of cranial hand palpates interspinous pace. Flex both knees to 90 degrees. Bring legs over to one side. This creates caudocranial rotation in the lumbar spine. Palpate for motion in the interspinous space.

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Central P-A’sPlace “manipulator dip” over spinous processes. Hand over hand. Then press vertebra in anterior direction. Assess range and quality of movement, and note changes in symptom behavior.

Unilateral P - A’s

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Rocking sacrumPatient prone. Palpate in interspinous space. With other hand rock pelvis back and forth. Feel for the willingness of the vertebrae to move. Can palpate up to C - T junction. Easy to pick up hypomobility. Not good for hypermobility.

Segmental rockingPatient prone. Straddle vertebra with thumb and index finger on each side of the TP’s. Can use hand over hand. Rock vertebra back and forth. Look for differences in quality of movement.

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Stability testing lumbar spine

Standing A-P shearPatient standing, hand over hand on abdomen. Find interspinous space, contacting both spinous processes with index finger. The rest of the hand flat against the back to stabilize. The other hand goes over patient’s hands. Give translatoric force in posterior direction, and palpate for movement in interspinous space.

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Sidelying A-P shearPatient sidelying. Palpate interspinous space, contacting both spinous processes. Flex hips to appr. 75 degrees. Knees contact therapist’s body. Give A - P pressure through long axis of femur. Palpate for available movement.

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Sitting A-P shearPatient sitting with hands on therapist chest/shoulders. Stand in front of patient, reach around under the arms. Fingertips of each hand are placed at the sides of the interspace of the involved segment. Patient gently pushes therapist away. This causes an A - P shear at the involved segment. If there is hypermobility, the superior SP will move posteriorly upon the inferior SP.

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Joint mobilizations

Principles of treating with mobilization Patient in maximally relaxed position Start articulating in resting position or as close to it as possible Use good body mechanics Stabilize one bone with belt or hand Articulate with the other No pain Never articulate in the close packed position

Supine distraction, generalizedPatient supine, hips and knees flexed. Place hands around proximal aspect of calves. Lean backwards to produce traction in the lumbar spine. If this alleviates symptoms, use as treatment.

Sitting distraction, generalizedPillow in back. Catch the low elbow. Distract with breathing pattern patient.

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Sidelying distraction, specificHips are flexed 60 - 90 degrees. Rotate trunk to cranial vertebra of segment to be treated. Cranial forearm and hand are placed against spine with index and middle finger fixating the cranial vertebra of the segment to be treated. The caudal arm and hand are placed on the sacrum, with the index and middle finger on the caudal vertebra of the segment. To apply traction, move caudal arm and body as a unit in caudal direction.

FlexionPatient sidelying. Hips and knees flexed. Rotate spine down to cranial vertebra of segment to be treated. Cranial hand fixates the transverse or spinous processes of the cranial segment of the targeted segment. Caudal hand is placed on the caudal vertebra. The PT’s body contacts the patient’s knees. The caudal hand and body produce flexion in the spine.

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Extension, sidelyingPatient sidelying. Hips and knees flexed. Rotate down to upper vertebra of segment to be tested. The index finger of the cranial hand on the spinous processes of the cranial vertebra of the segment to be treated. This provides the stabilization. The caudal hand is placed over the TP’s of the caudal vertebra. PT body contacts patient’s knees. Produce extension by moving the patient’s legs and pelvis in dorsal direction. Knee and hip joint angles remain fixed during the mobilization.

Extension, pronePatient prone. Manipulator dip over spinous processes, hand over hand. Articulate A - P.

Sidebending, pronePatient prone. Sidebending of the spine is initiated caudo - cranially by abducting the leg. Block the upper vertebra of the segment by placing your thumb lateral to the spinous processes. Abduct the leg until you feel the spine sidebend at the desired level, and then articulate.

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Sidebending, sidelyingGrasp medial aspect of paraspinals. One forearm on the ribcage, the other on the iliac crest. Then “break the bread”. (Pull paraspinals laterally while the forearms sidebend the lumbar spine to the opposite side. This is more of a soft tissue mobilization. To make it more of a joint mobilization, hook the fingers under the spinous processes, and then break the bread.

Gapping L spinePatient lies on side, with restricted side facing up. Flex hip and knee to the lower vertebra of the segment to be treated. Gently pull on lower arm to rotate down to the upper vertebra of the segment treated. The caudal forearm is placed over the gluteal mm. the thumb of your cranial hand is placed laterally on the spinous process of the cranial vertebra. Rotate the patient’s body towards you, to where the pelvis makes an 30-40 degree angle with the table. Bring your body weight up and over, and compress. Mobilize by pulling your caudal forearm towards you (80%) and pushing the cranial thumb in the direction of the table (20%) thereby gapping the upper facet joint.

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Down and back, unilaterallyFor left facet dysfunction. Patient in right sidelying. Extend the right leg up to the lower vertebra of the segment treated. Flex the upper leg, but not over 70 degrees. Pull on right arm to rotate down to the upper vertebra of the segment treated. The right forearm is placed over the glutes. The thumb of the left hand is placed laterally on the spinous process of the cranial vertebra. Mobilize by making a scooping motion with the right forarm in cranial direction (80%) and with the thumb of the left hand you move in the direction of the opposite hip (20%), thereby closing the left facet joint.

Multifidus isometric to joint capsuleUse: Non-specific stretch to the capsules of the facets, removal of capsular impingement.Patient prone over pillow. Caudal hand holds down the leg on the affected side at mid thigh. Cranial hand holds down the opposite shoulder. Patient is instructed to raise the leg, while therapist resists. Useful technique for acute lumbar facet entrapment where there is more of a “painful” than a “mechanical” block.

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Lateral shift correctionPatient standing. Therapist grasps pelvis as shown, bringing his shoulder into the patient’s arm, which is bent at their side. Gently correct the shift, can be rhythmic. If it hurts too much, back off, have patient slightly flex, then try again. To correct the shift might take up to a few minutes. Follow up with standing back bends or prone lying.

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