Lumbar Mobilization Techniques & Guidelines

• Lumbopelvic interventions are used in physical therapy.
• These interventions are for low back pain.
• Adam Squires PT, DPT, Cert SMT,Cert DN is Board Certified Specialist in Orthopedic Physical Therapy.

Objectives

• The goal is understanding the evidence behind physical therapy for low back pain.
• Clinicians should be able to perform lumbopelvic joint mobilizations using correct techniques.
• Clinicians should correctly perform lumbopelvic joint high-velocity and low-amplitude thrust manipulations.
• Muscle energy techniques for SI joint pain should be performed correctly.
• Clinicians should also have the skills to coach exercise interventions for the lumbopelvic region.

Deciding on Interventions

• How should clinicians decide on what interventions to use?
• Clinicians should consider these things:
  • What does the evidence say?
  • What has the patient already tried?
• Clinicians should identify beliefs and patient expectations.
  • What does the patient think is going on?
  • What does the patient thinking it will take to feel better?
  • What does success look/feel like to the patient?

Evidence Based Practice

• Best Available Evidence / Totality of Evidence includes Individual Papers and Systemic Reviews
• Clinical Expertise / Synthesis of Evidence includes Consensus Statements / Critical Thinking
• Patient Values / Circumstances includes Honest Informed Consent

What Does the Evidence Say?

• In 2021 the Academy of Orthopedic Physical Therapy of the APTA published Clinical Practice Guidelines (CPG).
  • This included Grade A evidence for mobilization and HVLAT manipulation with acute and chronic low back pain.
  • It also included Grade A evidence for exercise treating chronic pain.
• In 2017 CPGs were published by the American College of Physicians.
  • Strong recommendation for manual therapy and exercise with acute, subacute, or chronic LBP.
• In 2023 there was a Systematic Review of CPGs for WHO.
  • This review Recommended spinal manipulation and exercise.

Acute Low Back Pain Interventions

• Should Use for Acute Low Back Pain:
  • Exercise,
  • Manual and Other Directed Therapies,
  • Thrust or nonthrust joint mobilization,
  • Classification Systems, and
  • Patient Education.
• May use for Acute Low Back Pain:
  • Treatments with Treatment-based classification,
  • Active education and advice,
  • Addressing Biopsychosocial contributors to pain,
  • Self-management techniques, and
  • Understanding Favorable natural history.
  • Soft Tissue Mobilizations
  • Massage
• Can use for Acute Low Back Pain:
  • General exercise training
  • Mechanical Diagnosis and Therapy
• Knowledge Gaps (Level 1 RCTs Needed)
  • Movement Control, including Trunk mobility, Aerobic exercises, and Multimodal exercises
  • Neural tissue mobilization, Dry needling, and Traction
  • Cognitive functional therapy
  • Prognostic risk stratification
  • Pathoanatomic-based classification
  • Movement system impairment
  • Pain neuroscience education

Chronic Low Back Pain Interventions

• Should Use for Chronic Low Back Pain:
  • General exercise training, Muscle strengthening and endurance, Specific trunk activation, Aerobic and Aquatic exercises and multi modal exercises
  • Thrust or nonthrust joint mobilization
  • Active treatment (yoga, stretching, Pilates, and strength training)
• May use for Chronic Low Back Pain:
  • Movement control & Trunk mobility,
  • Soft tissue mobilization, Massage,
  • Mechanical Diagnosis and Therapy, Prognostic risk stratification and Pathoanatomic-based classification
  • Pain neuroscience education not as a stand-alone treatment & Active education not as a stand-alone treatment
• Can Use for Chronic Low Back Pain:
• Postoperative and General exercise training
• Thrust or nonthrust joint mobilization and Neural tissue mobilization and Dry needling
• Treatment-based classification and Movement system impairment
• Postoperative includes General education
• Knowledge Gaps (Level 1 RCTs Needed)
  • Comparisons of different approaches, Optimal dosing parameters, and Targeted delivery
  • Comparisons of manual therapy and active treatments & Value of manual therapy in multimodal approaches
  • Direct comparisons of different classification systems

ACP Clinical Guideline for Low Back Pain

• Description: The American College of Physicians (ACP) guideline to present the evidence and provide recommendations on noninvasive treatment of low back pain.
• Methods: Randomized trials and systematic reviews published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain.
• Target Audience and Patient Population: The target audience includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain.
• Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation. If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants
• Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation
• Recommendation 3: In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharm treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients.

Systematic Review of Clinical Practice Guidelines

• Objective: Identify evidence-based rehabilitation interventions for persons with non-specific low back pain (LBP) with and without radiculopathy and to develop rehab recommendations.
• Data Source: MEDLINE, EMBASE, CINAHL, PsycINFO, National Health Services Economic. Study Selection: Guidelines published between 2009 and 2019 in English, French, Italian, or Swedish, and including adults or children with non-specific LBP with or without radiculopathy.
• Data Synthesis: Four high-quality CPGs were identified
• Recommended interventions:
  • Education about recovery expectations, self-management, maintenance of usual activities
  • Multimodal approaches incorporating education, exercise, and spinal manipulation
  • Nonsteroidal anti-inflammatory drugs combined with education in the acute stage
  • Intensive interdisciplinary rehabilitation that includes exercise and cognitive/behavioral interventions for persistent pain
• No high-quality CPGs were found for people younger than 16 years old

Overview of Interventions

• Treatment Based Classification System (2016)
• Symptom Modulation: Manipulation/Mobilization, Specific Exercises, Traction
• Movement Control: Stabilization
• Functional Optimization: Strength and conditioning, Return to work, Return to sport

Symptom Modulation Overview

• Symptom Modulation includes:
  • Mobilization,
  • Manipulation,
  • Muscle Energy Technique,
  • Specific Exercises, and
  • Traction.

Mobilization Overview

• Mobilization:
  • Central PA (CPA),
  • Unilateral PA (UPA),
  • Lateral Glide, and
  • Rotation.

General Mobilization Principles

• Use firm but gentle touch. (Iron fist in velvet gloves.)
• Go slow
• Gradual increase in pressure and grade of mobilization based on patient feedback
• Maintain Patient & Therapist positioning as well as body mechanics
• Continuous assessment of patient response
• Communication, Communication, Communication!

Lumbar CPA / UPA

• Patient is prone, therapist standing to the side.
• CPA - Therapist places "dummy" hand hypothenar eminence over desired level spinous process.
  • Force being directly anterior with the mobilizing UE straight.
• UPA – Use "dummy" thumb approximately 1 thumb-width lateral to spinous process.
  • Applying force directly anterior with elbows straight.
• Perform for 30-60 seconds, 1-3 sets

Lumbar Lateral Glide

• Patient side-lying, involved side faces up with the therapist standing in front of patient.
• Patient knees together and hips flexed to ~60 deg flexion
• Therapist makes: Contact lateral muscle bulk with superior hand with forearms on hip and increasing the lateral side bend.
• Force: Applied toward to the table.
• Contralateral forearm is on hip and provides increased lateral side bend.

Lumbar Rotation

• Patient side-lying with painful side up. Lower leg straight, top leg foot tucked behind bottom leg knee.
• Arms are crossed holding onto forearms
• Therapist: Superior arm threads through patient top arm to hold trunk in place. Inferior hand contacts PSIS area.
• Therapist uses Mobilize using inferior hand while stabilizing with top arm.

Manipulation - Fritz 2007

• Recent onset of Sx (<16 days)
• No Sx distal to the knee and FABQ(W) score <19
• Hypomobility of the lumbar spine (CPA or UPA)
• Hip IR ROM >35 deg for at least 1 hip
• Interventions:
  • HVLAT (thrust) of the lumbopelvic region & AROM exercises

General Manipulation Information

• Is HVLAT safe?
• HVLAT is High-velocity, low amplitude thrust
  • Has to be quick enough that the patient could not stop it if s/he wanted to
  • Thrust duration 80-200 ms and average peak velocity 127 deg/s
• Use "Iron fists in velvet gloves".
• Use Fryette's 3rd law, prior to thrust to make it more. comfortable and, possibly, safer for the patient.
• Principle - Targets specific joints but will move several at once.
• Higher probability that needed joints move, if there is a lot to move.
• Not for realigning joints, but for modulating pain through neurophysiological pathways.
• DO NOT manipulate if patient Doesn't want manipulation!

Lumbar HVLAT Manipulation

• Rotation
• Thoracolumbar Junction (TLJ)

Lumbar Rotation HVLAT

• Therapist is standing in front of the Side lying patient.
• Patient LE + UE placement same as rotation mobilization.
• Patient underside scapula flat on table
• Table height should be such that therapist ASIS is above patient ASIS
• Therapist braces' the patient's trunk with superior hand
• Inferior hand placed over PSIS with fingers toward lumbar spine
• Apply Thrust toward the table with patient's pelvic 45 degrees anterior of neutral.

Thoracolumbar Junction HVLAT

• Patient long sitting on edge of plinth with Therapist on the side
• Patient clasps hands together behind their neck & Therapist wraps arm around opposite shoulder and supports CTJ
• Place a Contact hand in full fist, with spinous process of T12 between fingers and thenar eminence
• Perform Technique by lowering Pt onto contact hand and thrust applied directly into the table, and dropping toward floor.

Muscle Energy Technique (MET)

• Targeting SIJ and pelvis
• Correct dysfunctions using specific, isometric muscle contractions
• To correct anterior innominate:
  • Patient should stay as supine.
  • Therapist should provides resistance to hip extension on the involved side and hip flexion on the uninvolved side.
• To correct posteriorly rotated innominate:
  • Patient should stay in a supine position.
  • Therapist should provides resistance to hip flexion on the involved side and hip extension on the uninvolved side.
• "Shotgun" Technique - Pubic symphysis dysfunction:
  • Patient in a supine position.
  • Therapist resistance to abduction (3 reps) followed by adduction (1 rep).

Specific Exercise Overview

• Directional Preference Exercises (McKenzie or MDT)
  • Extension
  • Flexion
  • Lateral Shift Correction

General Info about Exercises

• Does this patient symptoms centralize with motion?
• Does the patient feel less intense with any movements?
• OR does the patientROM improve with motions?
• Often Disc issues get better to extension
• Often Stenosis issues get beat with flexion

Extension Exercises

• Sustained:
  • Increasing strength and endurance with Prone lying, Prone lying in extension & Prone lying with head of bed elevated.
• Dynamic:
  • Increasing strength and endurance with Prone press-up, Prone press-up with overpressure, & Standing Extension.

Flexion Exercises

• Flexion in lying:
  • Knees to chest, and increasing in vigor.
• Flexion in sitting, increasing strength and endurance.
• Flexion in standing and endurance.
• Increasing strength and endurance.

Lateral Shift

• MUST satisfy the following to be considered relevant:
  • Obvious shift of upper body,
  • Started with this episode of pain,
  • Patient can't correct or can correct but can't maintain, and
  • Correction affects symptoms in some way.
• Correct lateral shift first, if Relevant present.

Traction General Info

• Signs and symptoms of nerve root compression
• Patient symptoms do not centralize with any movements
• There are Manual and mechanical ways of performing traction
• Traction is best for Physical Agents

Manual Traction Techniques

• Use single leg with Hip extension, IR, and ADDuction
• Use double leg: Supine or Prone
• Knees Bent and pillow between you and patient
• Rock back into heels while Watching body mechanics
• Be Vigilant for lumbar extension

Movement Control and Mobility Exercises General Info

• Hodges and Richardson 1996
  • TA activation was delayed in patients with low back pain during movement of UE
• Hodges and Richardson 1998
  • Same finding with LE movement
• It led to the popularity of lumbar "stabilization"/motor control exercises
  • Activate deep core muscles in varying positions and prior to UE or LE movement to retrain movement/activation timing
• Graded exposure with Lederman statement is "The myth of core stability"

Lumbopelvic Stabilization

• Age < 40 years and Greater general flexibility avg.
  • SLR >91°
• Instability “catch” (aberrant motion) during trunk flexion or extension AROM
• (+) prone instability test and for Postpartum patients
• (+) positive Thigh thrust (posterior pelvic pain provocation or P4), ASLR and modified Trendelenburg tests and pain Provocation during palpation of long dorsal sacroiliac lig or pubic symphysis
• Promote isolated contraction and co-contraction of segmental stabilizing muscles (LM, TrA)
• Strengthen large stabilizing muscles
• IAP increases the function of other stabilizing mechanisms .

Lumbopelvic Stabilization positions

• Supine: Abdominal Hollowing/Pelvic tilt, Pelvic tilt with LE/UE movement, Pelvic tilt with Bridge
• Quadruped: Pelvic neutral and UE/LE movement, Plank
• Seated: Pelvic Tilt and UE/LE movements
• Standing: UE/LE movements & Lifts
• You Can Use previously discussed exercises and Hip mobility exercises for mobility
• Nerve glides and nerve tensioners

Functional Optimization

• SAID Principle stands for Specific Adaptation to Imposed Demand. Target Patient chain. What is best and more effective for Patient?
• Example: Is their job in an office OR construction?
• PT must know the needs of patient to prescribe the best exercise
• Take the Patients MEDS:
  • Meditation.
  • Exercise (strength and cardiovascular)
  • Diet.
  • Sleep (if no low quality of sleep increases pain)
• Focus on increased Strengths and endurance. -Untrained: 45-50 of one rep. -Trained is 80 one rep.
• Do 3-5 sets of 5-12 for strength.
• Improve their cardiovascular through;
• ACSM said 150 minutes of moderate intensity OR Vigorous intensity activity