NMT 200 Physical Medicine Lab PDF

NMT 200 Physical Medicine Lab Manual Mobilization and Manipulation Instructor: Dr. Albert Iarz, ND, RMT  Week 5: Learning Outcomes By the end of this lesson, students will be able: To have sufficient knowledge of lumbar anatomy and anatomical landmarks wit...

NMT 200 Physical Medicine Lab Manual Mobilization and Manipulation Instructor: Dr. Albert Iarz, ND, RMT  Week 5: Learning Outcomes By the end of this lesson, students will be able: To have sufficient knowledge of lumbar anatomy and anatomical landmarks within the context of motion palpation and mobilization contacts To readily assess the presence of common joint fixations in the lumbar and sacral spine Learn and practice lumbar and sacral mobilization techniques To understand when to apply mobilization techniques in a clinical setting  This lecture will be covering: Review anatomy of lumbar Indications, contraindications and risks Goals/effects of treatment Practitioner and patient positioning Demonstration of lumbar spine; Posterior to Anterior glides Superior glides Lateral glides Rotation glides Forward bending glide Backward-bending glide  The Lumbar Spine Greater amount of motion compared to thoracic spine due to absence of ribs. Responsible for most trunk mobility Must bear tremendous loads created by body weight that are involved with forces that are generated when lifting and other powerful movements Movement dictated by facet joints (L1-4, in sagittal plane) and (L4-5,L5-S1) facets are aligned closely with the frontal plane. Due to this difference, more forward and backward bending occur int he lower lumbar spine vs upper lumbar. Typical Lumbar Vertebrae is large. It is wider from side to side than from anterior to posterior L5 is atypical due to its slight difference in size compared to others (largest circumference body, shorter TVP’s but thick, SP is shorter and more rounded, facet orientation) Lumbar curve should be 40-60 degrees Anterior Pelvic Tilt can increase lumbar lordosis which places more weight bearing responsibility on facets Posterior Pelvic Tilt can decrease lumbar lordosis, which places more weight bearing responsibly on the discs Ligaments Anterior Longitudinal Ligament Posterior Longitudinal Ligament Supraspinous Ligament Interspinous Ligament Ligamentum Flavum Intertransverse Ligament Osteokinematic Motions in Lumbar Spine Forward Bending (Flexion) Backward Bending (Extension) Side Bending (Lateral Flexion) **this movement is naturally coupled with slight axial rotation of the vertebrae to the Contralateral side (Opposite side) of lateral flexion** Rotation (limited due to facet orientation) Lumbar Flexion (Muscles Involved) The control of flexion movements is largely a result of the: Eccentric contraction of the Erector Spinae (Sacrospinalis) muscles Although it is initiated by concentric contraction of the Psoas and Abdominals. The Iliopsoas flexes the spine when the femur is fixed, and the abdominal muscles flex the spine when the pelvis is fixed. During the first 60 degrees of flexion, the pelvis is locked by the Gluteus Maximus and Hamstrings But after 60 degrees, the weight of the trunk overcomes the stabilizing force of the Gluteal muscles and Hamstrings, and the pelvis rotates an additional 30 degrees at the hips. In full flexion, all the muscles are relaxed, except the Iliocostalis Thoracis (Thoracic segment of iliocostalis muscle), and the trunk is supported by ligaments and passive muscle tension. Lumbar Extension (Muscles Involved) Extension is initiated by: Concentric contraction of the sacrospinalis. Again, after the initial movement, gravity and eccentric activity of the Abdominal muscles become the major controlling forces in extension. Extension is limited by the ALL and anterior annulus and most significantly by bony impact of the spinous processes and articular facets. Lumbar Lateral Flexion (Muscles Involved) Lateral flexion is initiated by: Concentric contraction of the Quadratus Lumborum on the ipsilateral side And then immediately controlled by eccentric activity of the contralateral Quadratus Lumborum. Lateral flexion movement is limited by impact of the articular facets on the side of bending, and the capsular ligaments, ligamentum flavum, intertransverse ligament, and deep lumbar fascia on the contralateral side. Lumbar Rotation (Muscles Involved) Rotation is initiated by: Concentric activity of the abdominal obliques Assisted by concentric activity of the short segmental muscles (multifidus and rotatores) on the contralateral side. Rotational movements are controlled or limited by; Eccentric activity of the ipsilateral Multifidus and Rotatores The capsular, interspinous, and flaval ligaments. Balancing contraction of the contralateral muscles is important in maintaining the normal instantaneous axis of motion for axial rotation  Risks/Contraindications of Lumbar Spine Mobilization Minimal Risk Serious injury from a manipulation could result in Cauda Equina syndrome, but this is rare Pre-existing Conditions that are Contraindicated Ankylosing Spondylitis Inflammatory Arthrides Radiculopathy Lumbar Spinal Stenosis Spondylolisthesis Osteoporosis Lumbar spine fracture Skeletal metastases Cauda equina syndrome Scheuermans disease Scoliosis Disc Herniation (For Manipulations) Mobilization can be modified, but depends on stage of injury  Lumbar Mobilizations Indications Nonspecific Low Back Pain Sub-Acute or Chronic Not within 72 hours of injury or if moderate pain or inflammation, swelling, erythema, or bruising is still present Lumbar Radiculopathy due to hypertonicity of surrounding musculature Goals/Benefits Reduce Pain (widely accepted evidence-based) Restore optimal ROM of segment Restore quality of movement Improve proprioceptive function (Via vibratory nature of oscillation activating sensory mechanoreceptors) Segment specific via contacts placed on or close to segment being mobilized vs Manipulation (Grade 5) tends to have collateral effects. Improve kinetic chain function Reduce muscle guarding Compensatory mechanical stress on adjacent structures  Week 5 Practical Session- Lumbar Spine Assessments Mobility Scan through Motion Palpation Lumbar Mobility Scan: Sitting SITTING Position (Flexion/Extension Assessment) Patient is sitting with arms crossed (bear hug) Practitioner sits or stands behind the patient Place the non-palpating forearm across top of the patients posterior shoulder To test for flexion restrictions, place 3 fingers into the interspinous spaces and passively flex the patient’s torso forward, the spaces should open up (GAP increases). To test for extension restrictions, place 3 fingers into the interspinous spaces and passively extend the patient’s torso backwards, the spaces should close (GAP decreases).  SITTING Position (Lateral Flexion Assessment) Patient is sitting UPRIGHT (no slouching) with arms crossed (bear hug) Practitioner sits or stands behind the patient Contact patient’s ipsilateral shoulder with forearm Place thumb (contact) on the lateral surface of the SP’s on the side of INDUCED lateral flexion (Ipsilateral side) Take the patient’s torso and Laterally Flex them Ipsilateral (towards your testing side) The SP should move Ipsilateral (Into testing side) “Lumbar Lateral Flexion Loves you” Now challenge. Apply a lateral to medial force on SP to check for slight mobility. *** This is not a great picture for inducing lateral flexion. It can be done this way, however, your TA will show you a more effective and simple method** SITTING Position (Rotation Assessment) Patient is sitting UPRIGHT (no slouch) with arms crossed (bear hug) Practitioner sits or stands behind the patient Contact patient’s ipsilateral shoulder with forearm Place thumb (contact) on the lateral surface of the SP’s on the side of INDUCED rotation (Ipsilateral side) Take the patient’s torso and rotate them ipsilaterally (towards your testing side) The SP should move Contralateral (Away from testing side) *** I apologize for the picture. Our resources did not have a great lumbar image for rotation. The only adjustment needed to this image is that her thumb placement would be over the LUMBAR SPINAL SEGMENTS**  Lumbar Spine Mobilizations Posterior to Anterior glides Superior glides Rotation glides Lateral glides Forward bending glide Backward-bending glide  Posterior to Anterior Glide using the Transverse Process as a Lever Purpose To examine for lumbar spine joint impairment To increase accessory motion into lumbar joint anterior glide To increase range of motion at the lumbar spine To decrease pain Positioning 1. The patient is prone. 2. The lumbar spine is positioned in midrange in relation to forward/backward bending, side bending, and rotation. 3. The clinician is at the patient's side, facing the lumbar spine. 4. One hand is positioned with the anterior surface of the pisiform on the transverse process of one vertebra. 5. The other hand is positioned with the anterior surface of the pisiform on the opposite transverse process of the same vertebra. Procedure 1. Both hands simultaneously glide the TVP anteriorly (P to A) as the patient exhales  Superior Glide using the Spinous Process as a Lever Purpose To examine for lumbar spine joint impairment To increase accessory motion into lumbar joint superior glide To increase range of motion at the lumbar spine To decrease pain Positioning 1. The patient is prone 2. The lumbar spine is positioned in midrange in relation to forward/backward bending, side bending, and rotation. 3. The clinician is at the patient's side, facing the lumbar spine. 4. The stabilizing hand is positioned with the thumb or the anterior surface of the pisiform on the spinous process of the more inferior vertebra. 5. The mobilizing/manipulating hand is positioned with the thumb or the medial (ulnar) surface of the pisiform on the most inferior surface of the spinous process of the more superior vertebra Procedure 1. The stabilizing hand holds the inferior vertebra in position. 2. The mobilizing/manipulating hand glides the superior spinous process superiorly as the patient exhales  Lateral Glide Using the Spinous Process as a Lever Purpose To examine for lumbar spine joint impairment To increase accessory motion into lumbar vertebral body rotation and into facet joint distraction on the side toward which the vertebral body is rotating To increase range of motion at the lumbar spine To decrease pain Positioning 1. The patient is prone. 2. The lumbar spine is positioned in midrange in relation to forward/backward bending, side bending, and rotation. 3. The clinician is at the patient's side, facing the lumbar spine. 4. The stabilizing hand is positioned with the thumb or the anterior surface of the pisiform on the lateral surface of the spinous process of the more inferior vertebra. 5. The mobilizing/manipulating hand is positioned with the thumb on the medial (ulnar) surface of the pisiform on the lateral surface of the spinous process of the more superior vertebra opposite the side of the stabilizing hand. Procedure 1. The stabilizing hand holds the more inferior vertebra in position. 2. The mobilizing/manipulating hand glides the more superior spinous process toward the contralateral side of contact with the mobilizing hand, as the patient exhale  Rotation Glide in Side Lying Position Purpose To increase accessory motion into lumbar vertebral body rotation and into facet joint distraction on the side toward which the patient is rotating To increase range of motion at the lumbar spine To decrease pain Positioning 1. The patient is lying on the side not being treated with the arm resting over the clinician's mobilizing/manipulating arm. 2. The lumbar spine is positioned in midrange in relation to forward/backward bending, side bending, and rotation. 3. The clinician is at the side of the treatment table, facing the patient's anterior trunk. 4. The clinician locks the more inferior vertebrae by bringing the patient's knees toward the chest to the extent that the motion segment below the one being mobilized/manipulated is fully flexed, but the motion segment being mobilized/ manipulated has not yet moved. 5. The clinician next locks the more superior vertebrae by rotating the upper trunk away from the clinician (and in the direction of the intended vertebral body motion) to the extent that the motion segment above the one being mobilized/ manipulated is fully rotated, but the motion segment being mobilized/ manipulated has not yet moved. 6. One hand is positioned with the middle finger on the lower lateral surface of the spinous process (the side of the spinous process closest to the treatment table) of the more inferior vertebra and the forearm on the patient's pelvis. 7. The other hand is positioned with the thumb on the upper lateral surface of the spinous process (the side of the spinous process farthest away from the treatment table) of the more superior vertebra and the forearm or elbow anterior and medial to the patient's shoulder. Procedure 1. The clinician's hand on the more inferior vertebra glides the spinous process upward as the forearm rotates the pelvis forward and the patient exhales. 2. The clinician's hand on the more superior vertebra simultaneously glides the spinous process downward as the forearm rotates the upper trunk backward  Forward Bending Glide Mobilization with Movement (L1-L4) Purpose To decrease pain To increase pain-free range of motion into lumbar forward bending Positioning 1. The patient is sitting on the treatment table with knees bent over side. 2. The clinician stands with feet shoulder width apart, behind the patient. 3. The clinician places the hypothenar eminence of the mobilizing hand on the distal tip of the patient's spinous process by supinating the forearm and extending the wrist. 4. The clinician braces the elbow of the mobilizing hand against the clinician's pelvis for support. Procedure 1. The clinician imparts a superior glide to the vertebra, taking the joint up to tissue resistance. 2. While maintaining the superior glide, the clinician instructs the patient to bend forward at the hip as far as possible as long as the movement is pain-free. The patient is permitted to hold on to the treatment table to decrease the apprehension of falling forward with the forward-bending movement. 3. The clinician maintains the superior glide while the patient moves to the starting position. 4. The clinician continually adjusts his or her own position in relation to the treatment plane to maintain the joint mobilization force during joint movement Particulars A. This technique are indicated only if they can be performed without reproducing the patient's pain/symptoms. B. This technique should result in an immediate increase in range of motion and/or a decrease in pain. C. If effective (the technique results in an immediate increase in range of motion and/or decrease in pain), these techniques should be repeated (~2 to 3 times).  Backward Bending Glide Mobilization with Movement Purpose To decrease pain To increase pain-free range of motion into lumbar Backward bending Positioning 1. The patient is prone on the treatment table. 2. The clinician stands at the patient's side. 3. The clinician places the hypo-thenar eminence of the mobilizing hand on the distal tip of the patient's spinous process. 4. The clinician places the guiding hand on the patient's anterior inferior ribs for support. Procedure 1. The clinician imparts a superior glide to the vertebra, taking the joint up to tissue resistance. 2. While maintaining the superior glide, the clinician instructs the patient to bend backward as far as possible as long as the movement is pain-free by performing a push-up while keeping the pelvis on the treatment table. 3. The patient momentarily sustains overpressure to the joint once the patient completes movement into backward bending. 4. The clinician maintains the superior glide while the patient moves to the starting position. 5. The clinician continually adjusts his or her own position in relation to the treatment plane to maintain the joint mobilization force during joint movement Particulars A. This technique are indicated only if they can be performed without reproducing the patient's pain/symptoms. B. This technique should result in an immediate increase in range of motion and/or a decrease in pain. C. If effective (the technique results in an immediate increase in range of motion and/or decrease in pain), these techniques should be repeated (~2 to 3 times).