ADVANCED LUMBAR SPINE I

© The Manual Therapy Institute PLLC 1998-2018

CONTENT

Anatomy 3

SI joint and pelvic girdle revisited 8

Joint manipulations L spine 31

Soft tissue mobilization 32

Functional Movement Patterns 33

Adverse Neural Tension 35

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Anatomy

The lumbar disc

Function: Allow movement Transmit load from one vertebral body to the next

Requirements: Must be strong enough to sustain weight without collapsing Must be deformable to accommodate rocking motions of the vertebrae Must be strong enough not to get injured during movement

StructureThe nucleus is quite distinct in the center of the disc, the anulus is quite distinct at its periphery, but there’s no clear boundary between the both within the disc.

Nucleus pulposusThe nucleus is semi fluid, with the consistency of toothpaste. When subjected to force it attempts to deform and will thereby transmit the pressure in all directions, like a balloon filled with water.

The nucleus is 70-90% water. The next major components are the proteoglycans. They make up 65% of the dry weight of the nucleus and bind the water in the nucleus. Collagen makes up for 20% of the dry weight.

It’s the presence of water in large volumes that gives the nucleus its fluid properties. The proteoglycans and the collagen fibers account for the thickness and “stickiness”.

Anulus fibrosisWater is also the main component, 60-70%. Collagen makes up 50-60% of the dry weight. The tight spaces between the collagen fibers and each lamella are filled up with proteoglycan gel (20% of dry weight). This “glues” the fibers and lamellae together and prevents them from buckling or fraying. Elastic fibers are also present in the anulus (10%).In all movements the anulus acts like a ligament: it restrains and controls movement, and it stabilizes the joint.

The anulus consists of collagen fibers arranged in a highly organized fashion. The fibers are arranged in 10-20 sheets (lamellae), which are thicker towards the center. In the back they’re finer but more tightly packed. The orientation of the fibers is approximately 70 degrees from the vertical. If the fibers of the anulus were arranged perpendicular, they would give optimal resistance to distraction, but none to sliding motions. Oblique orientation can offer a component of resistance both vertically and horizontally so the anulus can resist movement in all directions.

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Mathematically it appears that 65 degrees of inclination is optimal for the various strains that the anulus has to sustain.The direction of fiber inclination alternates with each lamella. Every second lamella has therefore the same orientation. Thus at any time, the anulus can only resist twisting movement with half of it’s collagen fibers. Half of the lamellae will be stretched, while the other half will be relaxed. That’s one of the reasons why twisting motions are the most likely to injure the anulus. The lamellae don’t form complete rings; about half of them are incomplete.

EndplateTwo layers of cartilage cover the disc: the vertebral endplates. The endplates separate the disc from the vertebral bodies. Each endplate is a layer of cartilage 0.6-1 mm thick. They cover the nucleus completely but peripherally fail to cover the entire extent of the anulus. The endplates are strongly bound to the disc, but are only weakly attached to the vertebral bodies. Chemically, they resemble the rest of the disc. Towards the nucleus it contains more proteoglycans and water, towards the vertebral body it contains more collagen. This resemblance means that at a chemical level the endplate does not constitute an additional barrier to diffusion. This is why they’re regarded more as a part of the disc than of the vertebral body.

Part of the subchondral bone of the vertebral body is deficient (10%) and pockets of marrow abut against the surface of the endplate or penetrate into it. The pockets facilitate diffusion of nutrients to the disc.

NutritionThe disc receives no major arterial branches. Small branches do enter the disc but are restricted to the outermost fibers of the annulus. The discs are therefore dependent on diffusion. This comes from the vessels in the outer annulus and the capillary plexuses beneath the vertebral endplates.

There also have been studies to suggest that compression of the disc squeezes water out, and when pressure has been released, the water returns. This flux of water would then be capable of carrying nutrients.

MetabolismThe cells in the disc are metabolically active albeit at a low level. As the disc essentially lacks a blood supply, the cells therefore rely on diffusion for nutrition. Because of the low blood supply the oxygen concentration in the center of the nucleus is only 2-5% of that at the periphery. The cells must rely on anaerobic metabolism. As a result they produce large amounts of lactic acid, which makes the environment of the disc acidic. The metabolism in the disc is very sensitive to changes in pH.It functions properly at 6.9-7.2. Below 6.3 its activity falls below 15%. Impaired nutrition, inflammatory mediators or changes in pH can lead to major changes in matrix status.

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Weightbearing mechanisms IndependentThe anulus itself is a relatively stiff body. As long as the lamellae remain healthy, intact and are held together by the gel, it will resist buckling and is able to bear weight simply on the basis of it’s bulk (much like a telephone book wrapped into a cylinder and stood on its end). Under briefly applied loads, a disc without the nucleus has nearly the same weightbearing capacity as an intact disc. By itself it is extremely vulnerable to creep though.

Cooperation with nucleusThe nucleus provides an additional bracing mechanism. It can be deformed, but not compressed. When a disc gets compressed, it tends to reduce the height of the nucleus, which will then try to expand radially. This will then stretch the anular fibers, which will resist this deformation until equilibrium is reached. In a healthy disc with intact lamellae equilibrium is attained with minimum radial expansion of the nucleus. Besides trying to expand radially, the nucleus will also exert pressure towards the endplates.The advantage of cooperation of nucleus and anulus is that the disc is able to sustain loads that otherwise would buckle anulus acting alone. The essence of this combined mechanism is the fluid property of the nucleus, which makes the disc a stiff body. Since the water content of the nucleus is a function of proteoglycan content, any change in this will alter the mechanical properties of the disc.

Age changes With aging, the concentration of proteoglycans and the rate of proteoglycan turnover decrease. This means that the water binding capacity also decreases. It drops to 65% by age 75. The collagen fiber content of the nucleus increases and it starts to resemble the anulus more. The disc will become drier, more fibrous and less resilient with age. The decreased waterbinding capacity leaves it more vulnerable to creep.

After middle age, the distinction between the nucleus and the anulus becomes less apparent. The nucleus becomes less able to exert fluid pressure so a greater share of the vertical load is carried by the anulus, subjecting it to greater stress. In the annulus clefts and fissures may develop, not necessarily from external trauma, but mostly from repeated intrinsic trauma.

Narrowing of the disc has always been considered to be one of the signs of aging of the spine, but this appears to be not true. The disc actually increases in size with age. Maintenance of disc height is a “normal” feature of aging. Any loss of trunk stature with age is resultant from decrease in vertebral body height. A different explanation is required for disc narrowing, especially as it occurs at only 1:5 lumbar segments.

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Disc narrowing is a consequence of nucleus degradation following endplate fracture. Possible scenario: autoimmune response destroys the nucleus after the endplate fracture, as the disc proteins have never been exposed to the immune system. This is not quite proven though. Another explanation: endplate fracture destroys the delicate homeostasis of the nucleus, causing its degradation. More recently, research is focusing on hereditary and environmental factors as an important causal factor in disc degeneration (28).

Facet jointsThe facets are ovoid in shape, 16 mm high, and 14 mm wide. The joint surfaces are usually flat, but C- shapes and J- shapes (in transverse plane) happen frequently. The articular cartilage is thickest (up to 2 mm) at the center of the joint.

Around the dorsal, superior and inferior joint margins, a fibrous capsule, passing transversely from one articular process to the other, encloses the joint. Anteriorly, the capsule is absent, replaced by the ligamentum flavum. The capsule is thick dorsally, reinforced by deep fibers from the multifidi.

Intra articular structuresThere are 2 types of intra articular structures:

Fatty tissue that basically fills any left over space underneath the joint capsule. Located principally in sub capsular pockets at the superior and inferior poles of the joint. It communicates with the outside of the joint through foramina in the joint capsule.

Meniscoid structures, of which 3 types are recognized:

1. Connective tissue rim. This is a wedge shaped thickening of the internal surface of the capsule. It fills the space left by the curved margin of the articular cartilage. It’s thought to be simply a space filler although they might also serve to increase the surface area of the joint, which will help transfer loads.

2. Adipose tissue pads. Found at superior and inferior poles of the joint, consisting of synovial folds. They project approximately 2 mm into the joint.

3. Fibro adipose meniscoids projecting approximately 5 mm into the joint cavity from the inner surface of the superior and inferior capsules.

None of them is really a meniscus like the ones in the knee. They do have a protective function though. During flexion the inferior facet slides 5-8 mm up and forward. This exposes the cartilage on both facets. The meniscoids remain in contact with the exposed cartilage, thereby maintaining a film of synovial fluid on the cartilage. This ensures proper lubrication against friction as the joint moves back into its resting position.

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With age osteophytes are formed and mobility tends to decrease, especially after 30 years of age. It appears though that it’s not age changes in the facet, but increased stiffness in the disc that is responsible for the loss of mobility.

Spondylosis and osteoarthritis should not be necessarily seen as a disease, but more as an expected morphological change with age. Development of osteophytes is a body’s response to altered mechanics after the disc becomes stiffer. Osteophytes can occur around the entire margin of the vertebral body in response to excessive vertical load bearing, or focally anterior and posterior where strains are high during flexion and extension. By distributing those increased loads over a wider area, the stress on the anulus decreases during weight bearing.Also a most critical argument against viewing this as a disease is that they are so irregularly associated with symptoms or disability. Incidence of spondylosis and OA is just as great in patients with symptoms as it is in patients without symptoms.

References

1. Bellew J. (1996) Lumbar facets: An anatomic framework for low back pain. Journal of Manual and Manipulative Therapy. Vol. 4 No. 4,

2. Bogduk N. (1997) Clinical anatomy of the lumbar spine and sacrum, 3rd edition. Churchill Livingstone

1. Battie M. et al. (2008) The foundation of a new paradigm of disc degeneration: the twin spine study.

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SIJ and Pelvic Girdle

Pubic dysfunctions

Superior pubic dysfunctionsCause – extrinsic trauma Abnormal upward force through an extended leg Fall on ischial tuberosity Hip hyper flexion Sex, pregnancy, delivery

Cause – intrinsic trauma Hip AGMR

Symptoms Symphyseal, medial hip and thigh pain Pain with walking, stair climbing Standing on involved side

Signs Pubic tubercle is superior Tenderness over pubic tubercle Pubic joint motion restriction

Inferior pubic dysfunctionCause – extrinsic trauma Upward lift of the body with the foot fixed Hip hyper extension Sex, pregnancy, delivery

Cause – intrinsic trauma Hip AGMR

Symptoms Pain with hip flexion As with superior dysfunction

Signs Pubic tubercle is inferior Tenderness over pubic tubercle Pubic joint motion restriction

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Sacral dysfunctions

Sacral torsionA sacral torsion occurs as a result of sacral rotation and side bending to the same side.

For a left sacral torsion. The right sacral base flexes (which is left rotation) end the left side of the sacrum moves inferior (which is left side bending). This is the most common sacral torsion dysfunction.

Cause – extrinsic trauma Spinal rotation force Left hip hyperflexion- and/or right hip hyperextension injury

Symptoms Unilateral lumbosacral, gluteal pain Pain with walking, stairclimbing Pain on prolonged weightbearing on involved leg

Signs Deep right sacral sulcus, inferior left ILA Increased hip intrinsic external rotator muscle tone Decreased mobility SIJ/positive flick test

Unilateral sacral flexion injuryA unilateral sacral flexion lesion exists when the sacrum rotates in one direction and side bends in the opposite direction.

For a left unilateral sacral flexion dysfunction. This happens when the left side of the sacral base flexes (which is right rotation) and the left side of the sacrum moves inferior (which is left side bending). This is the most common unilateral condition.

Cause Spinal right rotation force Left hyperextension- and/or right hip hyperflexion injury

Symptoms Unilateral lumbosacral, gluteal pain Pain with walking, stair climbing Pain with weight bearing on involved side

Signs Deep anterior left sacral sulcus, inferior left ILA Tenderness left posterior SI ligaments Decreased mobility SIJ/positive flick test

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Sacral flexion/extension lesionsThese are somewhat difficult to diagnose, as there are no left/right asymmetries to palpate and no asymmetrical findings in motion testing. The patient will frequently complain of centralized low back pain in the sacral area, increased by sagital plane movements and transitional movements. Also look for deviation of the sacral position as it relates to the patient’s overall posture. Example: patient presents with kypholordotic posture, but the sacrum is relatively in extended position.

Flexed sacrum Patient presents with positive sitting flexion test bilaterally, which can be mistaken for a negative test. However, what you’ll find is that both PSIS move superior with the start of lumbar flexion. All landmarks are level. Flexion will be most limited.

Extended sacrumFrequently as a result of a sustained flexion trauma. Patient presents with positive sitting flexion test bilaterally. All landmarks are level. Sacral base and inferior lateral angles will be at the same level in the frontal plane. Extension will be most limited.

Diagnosis Flick test positive Sacral base position

ILA position

Right unilateral flexion

Right Anterior right Inferior right

Left unilateral sacral flexion

Left Anterior left Inferior left

Right unilateral sacral extension

Right Posterior right Superior right

Left unilateral sacral extension

Left Posterior left Superior left

Left sacral torsion Anterior right Superior right

Right sacral torsion

Posterior right Inferior right

Flexed sacrum Bilateral Anterior Posterior

Extended sacrum Bilateral Posterior Anterior

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Iliac dysfunctions

Motion tests (standing flexion test, Gillette’s, supine to long sit etc.) have poor intra and inter tester reliability. A systemic methodological review of motion testing of the SI joint could not demonstrate reliable outcomes. It was recommended that there was no evidence on which to base acceptance of mobility tests of the SIJ into daily clinical practice. It has been suggested that intertester reliability may be improved by combining results from several tests into a composite multi test score.

Two studies evaluated one method of combining the results of four tests to determine the presence of SI dysfunction (anterior/posterior rotated innominates), and had conflicting findings. The method used by Cibulka et al. required positive results from at least three of four tests before results were considered conclusive.

The tests used: standing flexion test, prone knee bending test, supine to long sitting test and sitting PSIS test. When the same four tests were reevaluated in a multicenter study by Riddle, the intertester reliability was found to be too low for clinical use.

The tests are presented with good intention, recognizing their failure to respond in isolation to reliability and validity studies. They remain the best we have and when clinical reasoning process is applied, a logical diagnosis can be made in regards to SIJ dysfunction.

Anterior ilium dysfunctions or posterior ilium dysfunctions are defined as being present if at least 3 of the 4 following tests are positive:1. Palpation bony landmarks2. Standing flexion test3. Supine to long sitting test4. Prone knee flexion test

Palpation of bony landmarksPalpate ASIS, PSIS and iliac crest.

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Standing flexion testPalpate PSIS bilaterally and have patient bend forward. A high riding PSIS indicates the site of fixation.

Supine to long sitting testPatient supine. Flex both knees up to chest to even pelvis out. Palpate distal part of medial malleoli. Have patient sit up, and palpate medial malleoli again. Look for positional changes. Short to long with crossover on the affected side is indicative of a posterior innominate. Long to short with crossover is indicative of an anterior innominate

Prone knee flexion test (Deerfield)Patient prone. Best done with shoes on. Distract both legs to even out pelvis. Bring feet together and palpate the heels of both feet, looking for leg length discrepancy. Then flex the knees to 90 degrees and check both heels again. Interpret as the supine to long sitting test.

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OutflareFor right outflare

Cause- extrinsic trauma Fall on the lateral aspect of the right PSIS

Symptoms Right lumbosacral, gluteal pain Pain with right hip adduction and/or internal rotation

Signs With patient supine, the right ASIS will be more posterior than the left With patient supine, the distance between the right ASIS and the greater

trochanter will be less than the left.

InflareFor left inflare

Cause – extrinsic trauma Fall on the lateral aspect of the ASIS

Symptoms Left sided lumbosacral, gluteal pain Pain with walking, stair climbing and prolonged weight bearing left LE Pain when sitting with legs crossed left over right

Signs With patient supine, the left ASIS will be more anterior than the right With patient supine, the distance between the left ASIS and the greater

trochanter is greater than on the right

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Palpation

Pubic tuberclesPalpate both tubercles with the first 2 digits of both hands to assess anterior/posterior and superior/inferior position

Posterior SI ligamentsOften irritated during SI dysfunction. Although not directly palpable, pressure just medial to the PSIS is often uncomfortable and is reflective of posterior SI ligament irritation.

Sacrotuberous, sacrospinous ligamentThe sacrotuberous ligament is assessed at its attachment on the inferior aspect of the PSIS, the lateral ILA and the medial aspect of the medial tuberosity. Tenderness indicates ligament involvement. Anterior or posterior iliac rotation can be the cause.Both ligaments are assessed through the gluteals for tension and pain, along a straight line from the ischial tuberosity to the ILA.

Sacrococcygeal junctionIdentify the sacral hiatus at the apex of the sacrum. The joint line of the sacrococcygeal joint is found just distal to the sacral apex and is palpated for sensitivity.

Sacral sulcusLocated just medial and slightly superior to the PSIS. Assess depth to evaluate sacral base position.

Inferior lateral angles of the sacrumPalpable just lateral from the sacrococcygeal junction. Palpate for sidebending positional faults

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Sacral mobility tests

Sacral flexion (backward bending test)Palpate both sacral sulci. Have patient bend backwards while shifting the pelvis forward (poke belly button out). Only slight increase in lumbar curve is needed. The sacral sulci should move anterior (the sacrum flexes on the initial phase of lumbar extension).

Sacral sidebendingPatient standing. Palpate both sacral sulci. Have patient sidebend. The sacral sulcus on the side patient is sidebending towards should move anterior (coupling of the sacrum follows that of the lumbar spine: sidebend and rotation are coupled opposite). Compare left to right.

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Sacral rotationPatient sitting. Palpate both sacral sulci and have patient rotate. With left rotation the right sacral sulcus should deepen and the left should become shallow.

Posterior translationPatient supine. Contact anterior to the ASIS on both sides with the thenar aspect of each hand. Apply a very gentle A-P pressure and assess the ease or resistance to motion. Increased resistance on the affected side is indicative of a hypomobility. Decreased resistance on the affected side is indicative of a hypermobility. Testing can also be done in posterior rotation, inflare or outflare of the ilium if so desired.

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Joint Mobilizations Pelvic Girdle

Anterior rotation ilium, pronePatient prone, pillow under abdomen, leaving ASIS unsupported. Stabilize caudal aspect of sacrum with right hand. The palm of the mobilizing hand is placed under the left iliac crest. Mobilize ilium in anterior rotation.

Anterior rotation ilium, sidelyingPatient in left sidelying. Left hip in maximum flexion (this locks the left ilium in posterior rotation), right hip slight flexion. Therapist’s right hand on right iliac crest. Heel of left hand on right ischial tuberosity. Use both hands simultaneously to rotate ilium anteriorly.

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Posterior rotation ilium, sidelyingPatient in left sidelying. Left hip extended (this locks the left ilium in anterior rotation), right hip and knee flexed. Ulnar side of therapist’s right hand is placed on the right iliac crest. Heel of the left hand is placed on the right ischial tuberosity. Use both hands simultaneously to rotate ilium in posterior direction.

Posterior rotation, prone

Mobilizations for the sacrum and the pubis are best done in a sustained type fashion, utilizing patients breathing. This is much like the MET for inferior/superior rib dysfunctions. Direct techniques with grade 4 oscillations at end range don’t have as much effect in this region and in most cases are very uncomfortable for the patient.

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Inferior pubis glideFor left superior pubis. Patient supine. Therapist stands on involved side at the head end. The base of the right hand contacts the superior aspect of the left superior pubic rami. The base of the left hand is paced on top of the right hand. Apply an inferior directed force.

Superior pubis glideFor left inferior pubis. Patient supine. Therapist on involved side facing the patient. Ulnar aspect of the left hand contacts the anterior aspect of the pubic body. Apply a superior directed force onto the left pubic body.

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Sacral sidebendingTo correct left sacral sidebend. Patient prone. Therapist stands on the left side of the patient at the feet end. Thenar aspect of the right hand contacts the inferior aspect of the left ILA. Mobilize in superior direction.

Alternative technique

Sacral rotationTo correct a left sacral rotation, with left sacral base stuck in extension. Patient prone. Therapist on the left side of the patient with the ulnar aspect of the right hand on the left sacral base. The left hand is placed over the right hand. Mobilize in anterior direction

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Sacral rotationTo correct a left sacral rotation, with right sacral base stuck in flexion. Patient prone. Therapist on the left side, facing pelvis. Ulnar aspect of right hand on left ILA. Left hand placed on right PSIS for stabilization purposes only. Mobilize with right hand in anterior direction.

Outflare, proneTo correct a left inflare. Patient prone. Therapist on the left side of the patient. Fingers of the left hand under left ASIS. Base of the right hand lateral to left PSIS. Left hand pulls ASIS laterally. Right hand applies a medial force to the PSIS.

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Outflare, supineTo correct right inflare. Use as a MET. The cranial hand is on the ASIS. The right hand is on the medial side of the knee. Resist hip adduction. Pick up the slack by abducting the hip and pushing the right ASIS in outflare

Inflare, proneTo correct a right outflare. Patient prone. Therapist on the right side at pelvic level. Right hand stabilizes the left sacral base. Left hand holds the right ankle with the knee flexed. Internal rotate the hip to inflare the ilium. Contract/relax works well in this case.

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Inflare, supinePatient supine. Cranial hand under PSIS. Caudal hand on iliac crest/ASIS. Mobilize by using sustained pressure in inflare: the cranial hand pulls and the caudal hand pushes.

Superior iliac glide, left sidePatient prone. Therapist on the left side at feet. Manipulator dip of right hand on ischial tuberosity. Apply a superior and slightly lateral force onto the ischial tuberosity.

Inferior iliac glide, left sidePatient prone. Therapist stands on the left side at head end. Hand over hand on superior aspect of the left iliac crest. Apply an inferior and slightly medial force.

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Manipulations Pelvic Girdle

SIJ prone, long axis distractionPatient prone. Assistant stabilizes sacrum, force directed anterior and superior. Therapist holds distal tibia. Hip in close pack position. Long axis distraction of the leg, thrust in caudal direction.

SIJ , supinePt supine, fingers laced behind neck elbows together under the chin. The pelvis should be close to the therapist; the feet and upper body are moved to the other side of the table, creating right sidebend of the trunk. Therapist then threads the right forearm, from the lateral side, through the gap between the patient’s right arm and chest and rests the hand on the table. Then rotate the body towards you, without losing the right sidebend, until the right ilium begins to lift. Place the left hand on the right ASIS, manipulate in posterior direction.

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SI joint, sidelyingPatient in left sidelying. His right hand holds the side of the table. The left hand holds the therapist’s hand. Patient’s lower leg is extended, the upper leg flexed. Therapist’s right hand is placed over the right PSIS. To stabilize the trunk, therapist pulls on patient’s left hand, which patient resists. Pick up the slack with the right hand on the PSIS in an anterior, slightly superior direction, then thrust.

SI joint, pronePatient prone, places hand next to shoulder and pushes up to the point where the pelvis starts to move. Look over the right shoulder. Therapist places caudal hand over PSIS. The left arm crosses under patient’s right arm, and the forearm engages the lateral ribcage. Compress with your abdomen towards the table, and with your forearm towards you. Pick up the slack in the ilium in anterior direction and apply the thrust.

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Sacral manipulation proneThis is a recoil technique where the PT applies a slight compressive force to the sacrum towards the table and then squeezes the sacrum to slightly compress it. The technique is performed with the release of tension allowing the natural recoil of the bone to act as the mobilizing force. Repeat 2-3 times. Most useful where despite performing other SI manipulations some dysfunction still remains.

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Muscle Energy Techniques Pelvic Girdle

Posterior rotation ilium, sidelyingFor left anterior innominate. Patient in right side lying. Therapist in front of hips. With right hand monitor movement in left sacral sulcus. With left hand flex left knee and hip until innominate has begun to move but the sacrum not yet. Resist hip extension for 6 - 8 seconds. Upon relaxation pick up the slack to new barrier by further flexing the leg. Repeat 3 - 4 times, then re-asses.

Anterior rotation ilium, pronePatient prone. The cranial hand contacts the back of the left iliac crest to monitor and as counterforce. With the caudal hand therapist lifts the left thigh. Sometimes that is easier done with the knee flexed 90 degrees. Avoid the patellofemoral joint. When the slack is taken up, instruct the patient to pull the knee down toward the table. Caution the patient not to pull too hard. At the moment of ease, take up the slack by lifting the thigh further.

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Anterior rotation ilium, supinePatient supine, with pelvis moved to the side of the table so that the right PSIS is just off the tabletop. For stability the shoulders should remain in the center of the table. Use your cranial hand to press down on the patient’s left ASIS, and then bring the right leg off the table. The left hand on the ASIS monitors, stop the right hip extension just before the left ASIS begins to move. Instruct the patient to carefully raise the right thigh. At the moment of ease, pick up the slack by further extending the right hip.

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Posterior rotation ilium, supinePatient supine. Flex hip and knee. Therapist’s caudal hand is placed under the left ischial tuberosity. The cranial hand is placed on the left ASIS. With deltopectoral groove you flex the hip until the slack is picked up. Instruct the patient to gently push the foot towards the end of the table. At the moment of ease you pick up the slack by rotating the ilium in a posterior direction.

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To correct left rotation of the sacrum, with right sacral base stuck in flexionPatient in left sidelying. Fully rotate trunk to the left. If T-spine is stiff, put a pillow under the chest for support. Flex hips up to the level of the sacrum. Drop the feet to the floor until you feel the soft tissue tightening up under your fingers, which are placed on the sacral base on the right. Action: “don’t let your legs drop to the floor”. Hold 6 seconds, and then bring feet towards the floor.

To correct right rotation of the sacrum, with right sacral base stuck in extensionPatient in left sidelying. Extend the lower leg. Fully rotate the trunk to the right. Patient holds the side of the table with his right hand. Flex hip up to the level of the sacrum. Resist abduction of the right leg, hold for 6 seconds. At the moment of ease you adduct the leg.

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References

1. Cibulka, M. (1989) Rehabilitation of the pelvis, hip and thigh. Clinics in Sports Medicine,

2. Cibulka M, Koldehoff R. (1999) Clinical usefulness of a cluster of sacroiliac joint tests in patients with and without low back pain. JOSPT Vol 29(2)

3. Goode, A. Hegedus, E. Sizer, P. Brsimee, J. Linberg, A. and Cook, C. (2008) Three dimensional movements of the sacroiliac joint: a systematic review of the literature and assessment of clinical utility. JMMT Vol. 16 No.1

4. Riddle D. et al. (2002) Evaluation of the presence of sacroiliac joint region dysfunction using a combination of tests: a multicenter intertester reliability study. Phys Ther

5. Oldreive, W.L. (1998)A classification of, and a critical review of the literature on syndromes of the sacroiliac joint. The Journal of Manual and Manipulative Therapy.

6. Lee, D. Instability of the SI joint and the consequences to gait. Journal of Manual and Manipulative Therapy, 1996.

7. Mens, J. Bekkeninstabiliteit. Oefentherapeutisch handelen, 1996.8. Vleeming, A. et al. Movement, stability and low back pain; the essential role of

the pelvis. Churchill Livingstone, 1997.9. Bourdillon, J. F. Day, E.A. and Bookhout, M.R. Spinal Manpulation, 5th edition.

Butterworth and Heinemann 199210. Hartman L. Handbook of Osteopathic Technique, 3rd edition. Cengage

Learning, Andover, 1997.

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Joint Manipulations Lumbar Spine

Mid lumbar spineMove patients shoulder out of the way. Extend lower leg, but not to the point where you extend the lower back. Rotate the body towards you 25-30 degrees. Lift your torso, and apply compression with your lower ribs to the pelvis. The right thumb is placed on the lateral side of the L5 SP. The forearm is placed on the gluteal mass. Components: compression down to the table, compression towards you, rotation of the trunk away, sidebending of the pelvis in cranial direction, pulling the pelvis towards you. Now hold your upper and lower levers firm, and roll the patient gently back and forth to engage the barrier. Apply the thrust by bringing your body weight down, and simultaneously bringing the right arm towards the table and the left arm pulling the pelvis anterior.

L5-S1Patient in sidelying. Rotate the shoulder out of the way. Flex the upper leg. Make sure you do not extend the lumbar spine when straightening out the lower leg, because the technique will not work that way. Sidebend caudocranially to localize to L5-S1 and compress down towards the floor with your trunk. Test the rotation primary lever, which at L5-S1 follows the direction of the upper femur. Add sidebend, and retest rotation. Then add flexion, and retest rotation. Build to the barrier, and apply the thrust by dropping your bodyweight, and by using the primary lever of rotation along the long axis of the femur.

From: D. Herbert. Osteopathic Technique Instructional Videos. With permission

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L5-S1 sidebending primary lever manipulation, lower facetSet up the patient in similar fashion as the previous technique. Therapist places caudal forearm between iliac crest and greater trochanter. The cranial arm reaches through a bit further, to where the thenar eminence contacts the sacrum. Push inwards, downwards and slightly pronate. Compress downwards with your body. Push down and towards the sacrum with both arms. Rotate the patient slightly towards you. Add caudocranial flexion and a bit more compression. Thrust by dropping your body downwards, in a caudal direction with your cranial hand.

From: D. Herbert. Osteopathic Technique Instructional Videos. With permission

Lumbar spine, up and forward, “breaking the bread”Patient in left sidelying. Rotate down to the level. Extend lower leg up to the level. Hook 3rd and 4th finger of the cranial hand under the spinous process of the superior vertebra, 3rd and 4th finger of the caudal hand under the spinous process of the inferior vertebra to be manipulated. Pick up the slack by simultaneously bringing the elbows down and the hands up, then thrust.

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Soft tissue mobilizations

Iliopsoas

Neuromuscular Re-education Supine single leg, hip and knee in flexion prolonged hold Supine single leg, hip and knee extended prolonged hold Seated single leg, hip flexion prolonged hold Quadruped rock back

Hip flexors in Thomas test position

Neuromuscular re-education Prone knee bend, hip extension

Breaking the bread

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Functional movement patterns (FMP)

Patient in half-kneeling to increase hip extension

Alternate mobilization positions Patient prone with knee flexion

L spine flexion

Neuromuscular re-education Patient seated, hands on floor or yoga block, extend knees and raise hips off

the chair

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Arm circles, with or without roll

NMR Latissimus stretch supine, seated or standing back against wall Latissimus stretch standing back against wall and sidebend holding opposite

elbow with hand

FMP using breathing and STM to lower border rib cage

Mobilization lumbar spine into extension use bilateral knee flexion, with patient prone

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Patient prone, mobilize in side-bending by taking leg into abduction

37

Adverse Neural Tissue Tension

STM to sciatic nerve, tibial nerve, peroneal nerve

SLR in and out of tension positions

Seated knee extension in and out of tension

Modified slump in sidelying, perform mobilizations to lumbar spine, soft tissue mobilizations to lumbar spine, sciatic nerve

Mobilization lumbar spine in flexion, anterior approach

Mobilization upper thoracic spine flexion with patient in slump position

38

Soft tissue mobilization to saphenous nerve in tension position

39