Manual Therapy Techniques For The Lumbar Spine

Original Editors - Jenny Arnatt, Tabitha Eddleston, Victoria Jovcic, Lizzie Wakeham as part of the Nottingham University Spinal Rehabilitation Project

Top Contributors - Tabitha Eddleston, Victoria Jovcic, Lizzie Wakeham, Jenny Arnatt, Kim Jackson, Admin, Rachael Lowe, Samuel Winter, 127.0.0.1, Tony Lowe, Johnathan Fahrner, Kai A. Sigel and Angeliki Chorti  

Introduction

In principle, any of the structures within the lumbar spine that receive innervation from the nervous system can be a source of back pain. Thus back pain can arise from any of the ligaments, muscles, fascia, joints or discs of the Lumbar Spine. Read more information on low back pain.

Mobilisations

Mobilisations primarily consist of passive movements which can be classified as physiological or accessory . The purpose is to provide short term pain relief and to restore pain-free, functional movements by achieving full range at the joint .

Joint mobilisation is a treatment technique which can be used to manage musculoskeletal dysfunction , by restoring the motion in the respective joint . The techniques are performed by physiotherapists and fall under the category of manual therapy. Spinal mobilisation is described in terms of improving mobility in areas of the spine that are restricted . Such restriction may be found in joints, connective tissues or muscles. By removing the restriction by mobilisation the source of pain is reduced and the patient experiences symptomatic relief. This results in gentle mobilisations being used for pain relief while more forceful, deeper mobilisations are effective for decreasing joint stiffness. . 

Effects and Mechanisms

Research has shown that mobilisation used as therapy can produce significant mechanical and neurophysiological effects    . The explanations of these effects - the mechanism of mobilisation - is still relatively unknown, especially in regards to the spine, and is subject to further research .
However, several theories have been established in accordance with the effects seen, including the effects of pain relief, increasing range of motion and the influence on the autonomic nervous system.

Pain Relief

Mobilisations offer pain relief through hypoalgesia - decreasing the nervous system's sensitivity to painful stimuli. There are various potential mechanisms of this neurophysiological effect:

1. Pain gating
   Pain gating refers to the theory that stimulation of the mechano-receptive peripheral afferent nerves in the muscles produce sensory input that interferes with nociceptive impulses at the spinal cord . The input from the larger sensory nerves inhibits the transmission of pain through the smaller nociceptive nerves to the brain, leading to a pain-relieving result . Therefore, the processes of stimulating mechanoreceptors via mobilisation produce short term pain relief through the mechanism of pain gating . However, the pain gate theory only explains the pain-relieving effect during the mobilisation, not any long term effects post-treatment. Therefore it is hypothesised that any longer-term pain-relieving effects are mediated by higher brain mechanisms
2. Descending mechanisms and supraspinal regions
   Research has shown that mobilisation leads to activation of pain inhibitory pathways that originate in the midbrain and travel down the spinal cord - the descending pathways   . The pathway stimulation works to provide pain relief by suppression of pain through this inhibitory mechanism.
   In addition to this these descending pathways, research has shown a trend where regions of the brain responsible for central pain processing are suppressed during mobilisation .
3. Adaptation
   It has been hypothesised that mobilisation promotes adaptations of the nervous system  with a decrease in the level of neural input from the painful site. Research also suggests that mobilisations increase the pain threshold levels - relative hypoalgesia . It has been suggested that this could be due to electrochemical changes in the regulation of threshold potential .

Increasing Range of Motion

Mobilisations are often used with the objective to increase the range of motion of the joint through stretching of fibrous tissue . This stretching may cause the tissue to 'creep'. The phenomenon of creep relates to the ability of tissues to change shape over time as a constant load is applied. The creep deformation is not permanent and, once the load is removed, the tissue will slowly resume its original length . However, in the short term, this mechanical effect of mobilisation enables an increase in range of motion at the joint.

Influence on Autonomic Nervous System

Mobilisation has been found to influence sympathetic activity, affecting heart rate, blood pressure  and respiratory rate . These sympathetic responses could possibly be linked to another evidenced effect of mobilisation - changes in blood component levels. Teodorczyk-Injeyan et al (2006) found that mobilisation effected the levels of blood components, with a reduction in inflammatory proteins. Therefore it was suggested that mobilisation could be a potential therapeutic modality to reduce inflammatory response - working as an anti-inflammatory mechanism, though the exact explanation for this process is unknown .

Bialosky et al (2009) suggested that the mechanical and neurophysiological effects explored here are interlinked. They proposed that a mechanical force initiates a chain of neurological responses, which would then produce the outcomes associated with manual therapy.
This proposal was illustrated in their model of the mechanisms of manual therapy.

The effects of mobilisation and the mechanisms responsible are not fully understood and more research is needed to provide evidence for the theories discussed. It is also important to note that variables such as the placebo effect and psychological factors may also pertain to the effects seen . 

Effects of Mobilisation on Stiffness and Pain

Mobilisations involving pressure onto the vertebra can be used to increase joint range of motion, and also to produce and analgesic effect.

Manual therapy and mobilisations can be used to treat 5 symptom groups:

• Pain
• Stiffness
• Pain associated with stiffness
• Momentary jabs of pain
• Disorders directly related to a specific diagnosis

Stiffness

For patients whose joint stiffness is limiting normal function. First, assess the patient's movement using physiological movements, select the movement that has limited ROM and needs to be stretched. Then accessory movements can be used. Pressure applied through the thumb or pisiform against the vertebrae in the direction of the movement that is stiff.

Staccato techniques are used to move a stiff joint through its maximum range before the bordering joints have time to start moving as well. If there are no symptoms from the joint, then the speed of the staccato can be quicker, however, if symptoms are moderate, then the movements need to be more fluid.

There is evidence to suggest that different segments of the lumbar spine will react slightly differently, for example; when a PA is performed on L3, 4 and 5, they tend to move into extension, and all three segments will move in response to a PA on one vertebra. However, with L1 and L2, the lower L3, 4 and 5 segments move relatively into flexion. The physiotherapist needs to be aware of the effect of a PA mobilisation on neighbouring vertebra segments

Pain

For patients who have severe pain that is limiting movement. The joint being treated should be positioned in a symptom-free way. To decide between accessory movements and physiological movements, the one, which can be performed with the larges amplitude of movement, most comfortable for the patient, is used. If a joint is painful, oscillations in mobilisations should be smoothly and even, so that changes between the on and off pressure cannot be detected.

Types of Mobilisations

Mobilisations can significantly decrease localised pain in the short term, about 24 hours, and can potentially lead to a greater decrease of pain long term compared to no treatment . To most effectively treat the pain, the symptomatic level of vertebra should be selected rather than a randomly selected level

Accessory Movements

• Pressure is applied through the thumb or pisiform to produce large amplitude of movement, with very little pressure and without any degree of stiffness felt.
• The amplitude of the movement should be as large as possible without causing any pain. As symptoms improve, then the amplitude of the movements can increase gradually, although mobilisations have been shown to have a beneficial hypoalgesic regardless of amplitude. 

Physiological Movements

When these are used they should not cause any discomfort

• Any movements should be in the painless direction, in a large, slow, smooth manner, stopping before the onset of any discomfort. As the patient’s symptoms and ROM improve, the technique can be taken into a known and controlled degree of discomfort.

Grading Mobilisations

Mobilisation techniques can be performed in different positions of the range, using small or large amplitudes of movements, which are divided into four grades.

Grade of Movement

I A small-amplitude movement near the starting position of the range

II A large-amplitude of movement that carries well into the range. It can occupy any part of the range that is free of any stiffness or muscle spasm that does move into stiffness or muscle spasm

III Also a large-amplitude movement, but one that does move into stiffness or muscle spasm

IV A small-amplitude movement stretching into stiffness or muscle spasm

Contraindications/Precautions to Vertebral Mobilisations

• Neurological:
  • Patient with arm pain and neurological signs, from two nerve routes
    Disturbance of bladder and bowel function, or perineal anaesthesia
    Spinal cord symptoms

• Radiological changes:
  • Patients with rheumatoid arthritis and osteoporosis are contraindications to forceful mobilizations.
    Any pathology leading to significant bone-weakening such as tumours, infections, long-term corticosteroid medication, fracture
  • Patients with vertigo need close supervision
• Hypermobility:
  • If a vertebra in the spine was hypermobile compared to the other vertebra, care must be taken to avoid putting excessive strain on the hypermobile joint

• Vascular
  • Aortic aneurysm, bleeding into joints, e.g. severe Haemophilia

• Pregnancy
• Musculoskeletal deformity
  • Spondylolysis, spondylolisthesis

Mobilisations of the Lumbar Spine

Passive Physiological Intervertebral Movements (PPIVMs)

Passive Physiological Intervertebral Movements (PPIVMs) are most often used in an assessment capacity rather than as a treatment therapy. PPIVMs are used to determine a range of properties of spinal movement that will guide the use of manual therapy techniques . PPIVMs test the movement available at the spinal level identified by application of a passive physiological motion  and palpating between adjacent spinous process or articular facets . While the therapist passively moves the spine they can note the range of motion, any muscle spasm or provocation of pain . They can confirm any restriction of motion seen in active movement and can also identify hypermobility . Additionally the spine can be taken to the end of range and there the therapist can apply over pressure to assess the end-feel of the movement . In this way PPIVMs can help the therapist to identify location, nature, severity and irritability of symptoms.

Reliability

Research has shown that PPIVMs have a good intra-tester reliability . However, the inter-tester reliability has often been questioned and some research has reported it to be poor  . Research has shown that PIVMs testing in flexion has high specificity (99%) but low sensitivity (5%) .

Method 

(see Fig. 1) 

• The patient lies on their side with hips and knees flexed . The therapists positions themselves in front of the patient.
• The therapist reaches under the patients knees, lifting them up and resting the patients lower legs against the therapists upper thighs.
• Leaning over the patient the therapist places one arm over the patients scapular to prevent backward rotation of thorax.
• The therapist places their fingers on the spinous process of the segment to be assessed for movement
• To produce passive flexion the therapist rocks from side to side with their pelvis, carrying the patients legs along with them.
• Opening and closing of the interspinous gaps can be felt as the patient is passively flexed.
  
  From this position passive extension can also be assessed.
  
  When palpating/assessing the lower lumbar spine the movement will need to be performed in relatively more flexion when assessing the upper lumbar spine movement .
  

                                                                           Fig 1. Physiological flexion positioning

PPIVMs in Alternate Planes

• Beyond Flexion Extension, Lumbar PPIVMs and PAIVMs can be performed in Extension, Side-flexion, Rotation and in a combination of planes

Side-flexion

• The pt is positioned in side lying facing the PT. They are asked to slide close to the edge of the table.
• PT’s cranial arm hooks under the pt’s top arm & the PT’s hand palpates for segmental motion.
• PT’s caudal hand holds the pt’s legs above the ankles with the pt’s legs against the PT’s thighs.
• Side bending motion is introduced by the PT’s arms & body by raising or lowering the patients distal legs. Can do ipsi- & contralateral SB.
• Overpressure (PAIVM) can be done with cranial hand while stabilizing the bottom segments through the pelvis.

Rotation

• The pt is positioned in side lying facing the PT. They are asked to slide close to the edge of the table.
• PT’s cranial arm hooks under the pt’s top arm & the PT’s hand palpates for segmental motion.
• PT’s caudal arm stabilizes the pt’s pelvis against the PT’s body & the caudal hand palpates for motion of the inferior segment.
• Rotation motion is introduced by the PT’s cranial arm & body.
• Overpressure (PAIVM) can be done with cranial hand while stabilizing the bottom segment with the caudal hand.

Central Posteroanterior (PA) Mobilisation Technique

A Passive accessory intervertebral movement (PAIVM) is a mobilisation technique that produces movement of a mobile vertebral segment without the active participation of muscles related to the movement. Posteroanterior (PA) mobilisations of the lumbar spine are achieved by applying a force on to a vertebral segment in a posteroanterior direction (Back to front).

• PA mobilisations are a commonly used manual therapy technique that has shown to be effective at reducing pain in patients with low back pain (LBP) . So far, evidence suggests immediate pain relief following treatment, and also some evidence suggests an increased range of movement (ROM) of lumbar extension   . However, literature is still variable on the overall effects of ROM and pain.

• During flexion, the superior vertebral body and its inferior facet joints move relatively anteriorly and superiorly on the inferior vertebral body and its superior facet joints. Therefore, to aid flexion the mobilisation needs to be applied to the vertebra above the stiff/painful vertebra to facilitate the anterior-superior translation of the facet joints.

Technique

Starting Position (see Fig. 2):

• Patient lying in prone
• Therapist stands to side of patient placing their pisiform/ulnar surface of hand over the selected spinous process (SP) with their wrist in full extention. Other hand placed ontop of hand to reinforce. (See Fig. 3).
• Therapist's shoulders should be directly above the SP with elbows slightly bent.

Method

• Therapist uses their body weight to apply a PA force to the selected SP by leaning their body over their arms and performing rocking movements to provide oscillatory movements of the vertebra.

On initial assessment and treatment, if the patient has very limited movement, a pillow can be placed underneath their abdomen, or the head end of plinth can be raised to position the Lumbar spine in relative extension. Similarly, if the patient cannot tollerate pressure directly through the spinous process, the therapist can apply pressure either side of the SP  with either thumb on the transverse processes (bilateral PA).

Equally, as the patient’s pain and stiffness reduces the position of the patient can be altered to increase flexion nearer to end of range. This can be done by either lowering the foot section of the plinth (see Fig. 4) or kneeling the patient on the floor by the foot of the plinth with his trunk flexed over the plinth ( approx. 20 degrees flexion) 

                                          Fig. 2. Central posteroanterior mobilisation technique with lumbar spine in neutral

                                                                            Fig. 3. Hand positioning for central PA

                                                                Fig. 4. PA mobilisation technique with lumbar flexion

Mobilisations with Movement (MWMs)

Mobilisations with Movement is a manual therapy technique which was developed by Brian Mulligan, for the treatment of musculoskeletal dysfunction . It involves performing a sustained force (accessory glide) while a previously painful (problematic) movement is performed.

Usually, the technique is indicated if, during its application, the technique enables the impaired joint to move more freely without pain or impediment.  Mulligan does not prescribe grades of movement or oscillatory movements. He prescribes taking the joint through its full range of movement and this entails taking it into resistance. When performing MWMs, the direction of the applied force is typically perpendicular to the plane of movement or impaired action and in some instances, it is parallel to the treatment plane .

There have been reports of clinical cases and case series which have described the success of MWMs in the management of various musculoskeletal conditions. See Exelby for success in MWMs in the lumbar spine

MWMs to increase Flexion of the Lumbar Spine

Key MWMs:

1. Side-lying flexion-extension
2. Central and unilateral SNAG in standing
3. Standing belt lumbar traction
4. Snag in four-point kneeling

Technique One

Starting position

• Patient is in side-lying facing therapist.
• The patient's knees should be bent towards their chest in mid lumbar flexion and rested on the therapist's hips.
• The therapist places their forearms along the patients back to palpate between adjacent spinous processes.

 Method

• The therapist produces flexion and extension of the lumbar spine by swaying hips left to right (and vice versa)
• To isolate flexion, the problematic level is palpated and when passively moving the spine into flexion a sustained PA force is applied to the spinous process throughout the movement of flexion and then released.
  

N.B *Correct plinth height is essential for this technique.

      ** It may take multiple attempts of the MWMs to find the correct level of the lumbar spine to decrease pain and/or stiffness.

Technique Two

Starting Position (See Fig. 5):

• Patient in standing perpendicular to the therapist.
• Therapist's need to stabilise pelvis via placing the cup of hand other the ASIS.
• Therapist to palpate between adjacent spinous processes.

Method

• The patient actively flexes the lumbar spine and then extends to return to the neutral position.
• To isolate flexion, again, the problematic level is palpated and when the patient actively moves into flexion, a sustained PA force is applied to the spinous process throughout the movement.

                                                                            Fig. 5 Flexion in standing technique

Technique Three

Starting Position (See Fig. 6):

• Patient in sitting, facing away from therapist.
• The pelvis is stabilised via a belt being placed around the patients ASIS's and around the therapist's ischial tuberosity. 
• Therapist to palpate between adjacent spinous processes.

Method

(See Fig. 7)

• The patient actively flexes the lumbar spine and extends to a neutral position.
• The therapist maintains the tension on the belt throughout all movement.
• The problematic level is palpated and when the patient actively moves into flexion, a sustained PA force is applied throughout the whole movement of flexion to the spinous process.

N.B * The therapist should have bent knees and be able to lean onto the belt to increase the tension of the belt. 

                                                                          Fig. 6. Flexion with belt in sitting upright

                                                               Fig. 7.  Flexion with belt in sitting with forward flexion

Technique 4: Snag in four-point kneeling

Patient starts in four-point, therapist places hand under stomach and over sacrum

We gently guide the patients buttock towards their feet

We apply a snag as the patient moves between flexion and tension

Recording

Prescription of Mobilisations

Thus far, there is no definitive evidence for the optimum duration, frequency or amplitude for mobilisation techniques. Most researchers have investigated subject responses' to 3 cycles of 60-second mobilisation which have shown to have immediate effects of local and widespread analgeia  . However, the duration, rate and frequency of mobilisations should be tailored to the patient's irritability and the preference of both patient and therapist. Current guidelines suggest that non-specific LBP patients should receive a 12-week course of manual therapy

Moreover, it is generally agreed that the oscillation depth and amplitude of movement are dependent on the patient's symptoms.
If the patient's main symptom is pain then oscillation depth should remain shallow (<55%) and should be maintained within a pain-free range (e.g. Grade I and II). However, if the patient's main complaint is of stiffness then the depth of oscillation can progress to end of range providing pain is tolerable (e.g. Grade III and IIII). Refer to section 2 for Maitland scale.