NMT 200 Physical Medicine Lab PDF

NMT 200 Physical Medicine Lab Manual Mobilization and Manipulation Instructor: Dr. Albert Iarz, ND, RMT  Week 6: 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 6: 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 spine Learn and practice lumbar spine mobilization techniques To understand when to apply mobilization techniques in a clinical setting  This lecture will be covering: Identify assessment techniques for lumbar spine function Lumbar anatomy review Identify the indications/contraindications of HVLA treatment within the lumbar spine. Outline the steps in performing the following HVLA on the lumbar spine: Lumbar Roll Spinous Hook Disc Closure Spinous Push  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 Manipulation 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  Understanding Problematic Segmental Coupled Lateral Flexion/Rotation Fixation Types Type 1 (Normal Coupling Pattern) Lateral Flexion is associated with coupled Axial Rotation to the OPPOSITE side (Contralateral) This produces the pattern where posterior body rotation occurs towards the contralateral side of Lateral Flexion This causes the Spinous Process to rotate towards the ipsilateral side of Lateral Flexion “LUMBAR LATERAL FLEXION LOVES YOU” This means that during assessment, the SP will move into your TESTING THUMB **Differs from thoracic lateral flexion** Apply a lateral to medial force on SP to challenge the mobility of it. It should have a bit of give (Mobility) Normal motor control is exerted though ECCENTRIC unilateral contraction of the contralateral Quadratus Lumborum muscle Type 2 (Abnormal Coupling Pattern) - Rotary Type Fixation Lateral Flexion is associated with coupled ABNORMAL Axial Rotation to the SAME side (Ipsilateral) This produces a dysfunctional pattern where posterior body rotation occurs towards the Ipsilateral (same) side of Lateral Flexion as opposed to the contralateral side. This causes the Spinous Process to rotate AWAY to the contralateral side of testing *Causing a coupled rotary fixation* IN ORDER TO ASSESS FOR A TYPE 2, LATERAL FLEXION ASSESSMENT IS ABNORMAL BUT ROTATIONAL ASSESSMENT IS NORMAL A muscular imbalance of the Contralateral Sacrospinalis exists (especially the Longissimus and Spinalis portions). ****Lesion is contralateral to testing side**** Type 3 (Diverging from Normal Coupling Pattern) Lateral Flexion is associated with either NO movement or movement in the direction opposite the lateral bending of the trunk This causes the Spinous Process to rotate still normally towards the ipsilateral side of Lateral Flexion (Testing Side) Apply a lateral to medial force on SP to challenge the mobility of it. If it doesn’t move or is stiff, this is a type 3 This is RARE and thus we will not be learning the manipulation for it Theorized to result from faulty disc mechanics/closure or over dominance of the QL Type 4 (Abnormal Lateral Flexion combined with Abnormal Rotation) Lateral Flexion is associated with abnormal coupled rotational movement During Lateral Flexion the SP moves to the contralateral side (OPPOSITE) of testing thumb (Abnormal) AND A dysfunctional pattern exists where a proper rotational assessment needs to be done on the contralateral side of lateral flexion, to see if the SP moves into the “new” testing contact during rotation. Which would make this (Abnormal) Lateral Flexion movement is dysfunctional as well as contralateral Rotational movement IN ORDER TO ASSESS FOR A TYPE 4, LATERAL FLEXION AND CONTRALATERAL ROTATIONAL ASSESSMENTS MUST BOTH BE ABNORMAL A muscular imbalance of contralateral Mulitifidus Muscles ****Lesion is contralateral to testing side of Lateral Flexion and Ipsilateral side of Rotation Assessment***  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. 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)  Lumbar Manipulations (Grade 5 HVLA) 1. Lumbar Roll 2. Spinous Hook 3. Disc Closure 4. Spinous Push  Lumbar Roll Indications Coupled Rotary type fixation Posterior rotation mal-fixation (Type II fixation) from L1-L5 Can also be done on T11-T12 Assessment Lumbar Assessment (Rotation and Lateral Flexion) Lateral Flexion - SP moves away from testing side (Abnormal) Rotation - SP moves away from testing side (Normal) Patient Position Side posture (Lesion side DOWN) Head piece elevated or pillow used to elevate head Pull on the lower arm and fold over the top shoulder stabilizing with the indifferent hand and provide traction superiorly Lower leg slightly bent at the knee Upper leg flexed with upper foot place in the popliteal space (behind knee of lower leg) done to provide rotational traction Pelvis must remain at 90 degrees to the table (perpendicular to take) Practitioner Fencer (lunge stance) Position Pelvis of the doctor is level with the affected spinal segment Bent upper leg of the patient between the Practitioner’s thighs Practitioner performs a thigh to knee contact with patient Practitioner’s torso should not rotate and spine should be straight The forward leg carries the majority of the practitioner’s body weight Contact Point Contact Hand: Pisiform of contact hand on Mammillary process of the subluxated vertebra Fingers point superiorly and run parallel to the spinous column Indifferent Hand: On superior shoulder holding patient’s lower arm and providing superior traction while holding them in posterior rotation (Shoulder being pushed up and back) Joint slack Remove joint slack with contact hand by pressing against the mammillary body and adding enough hip flexion and upper body traction/rotation Line of Drive Posterior to Anterior Thrust Leg and body drop on the patient while the contact hand pushes on the mamillary process P to A Order of Adjustment: 1. Upper (indifferent) hand traction 2. Contact hand pushes into mamillary process towards the practitioner 3. Drop down on thigh slowly with weight first 4. Body drop once traction has reached end stage Contraindications Spondylolisthesis Acute lumbar disc lesion (herniation)  Lumbar Spinous Hook Indications Superior fibers of the sacrospinalis muscle L1-L5 in spasm Coupled Rotary type fixation Posterior rotation mal-fixation (Type II fixation) from L1-L5 Can also be done on T11-T12 Assessment Lumbar Assessment (Rotation and Lateral Flexion) Lateral Flexion - SP moves away from testing side (Abnormal) Rotation - SP moves away from testing side (Normal) Patient Position Side posture (Lesion side DOWN) Head piece elevated or pillow used to elevate head Pull on the lower arm and fold over the top shoulder stabilizing with the indifferent hand and provide traction superiorly Lower leg slightly bent at the knee Upper leg flexed with upper foot place in the popliteal space (behind knee of lower leg) done to provide rotational traction Pelvis must remain at 90 degrees to the table (perpendicular to take) Practitioner Fencer (lunge stance) Position Pelvis of the doctor is level with the affected spinal segment Bent upper leg of the patient between the Practitioner’s thighs Practitioner performs a thigh to knee contact with patient Practitioner’s torso should not rotate and spine should be straight The forward leg carries the majority of the practitioner’s body weight Contact Point Contact Hand: Middle finger on contralateral side of the involved spinous process Hand and forearm rest on the superior ileum of the patient Practitioner’s elbow is kept close to the torso Indifferent Hand: On superior shoulder holding patient’s lower arm and providing superior traction while holding them in posterior rotation (Shoulder being pushed up and back) Joint slack Remove joint slack with contact hand by pressing against the Spinous Process and adding enough hip flexion and upper body traction/rotation Line of Drive Medial to Lateral Thrust Leg and body drop on the patient while the contact hand hooks the SP from medial to lateral Contraindications Spondylolisthesis Acute lumbar disc lesion (herniation)  Disc Closure Indications Disc closure issue, faulty mechanics, or over active QL Type 3 fixation from L1-L5 Can also be done on T10-T12 Assessment Lumbar Assessment (Lateral Flexion) Lateral Flexion - SP moves into testing side but is challenged and remains fixed (Abnormal) Patient Position Side posture (Lesion side DOWN) Side lying (lesion open disc wedge side up) with NO torso rotation Maximal elevation of the head and knee pieces of the table Arms folded on chest or shoulders and stabilized by indifferent hand Practitioner Fencer (lunge) stance Position Pelvis of the doctor is level with the lesion on the patient Lower leg slightly bent at the knee Upper leg flexed with upper foot place in the popliteal space (behind knee of lower leg) done to provide rotational traction Locate the lesion and monitor interspinous movement above and below the lesion while flexing the patient’s leg Practitioner’s torso should not rotate and spine should be straight Contact Point Contact Hand: Reinforced second finger in the interspinous space Forearm wraps around the pelvis and is resting on patient’s ileum Indifferent Hand: Forearm and hand are placed over the patients shoulder Joint slack Remove joint slack with contact hand by pressing in against the interspinous space and adding enough hip flexion and upper body traction Line of Drive Forearm contacts accentuate a C curve in the patient’s spine Line of drive is directly downward on to the lesion site Thrust Inferior to produce a closure of the non-functioning disc space Contraindications Spondylolisthesis and Acute lumbar disc lesion (herniation)  Spinous Push Indications Superior fibers of the sacrospinalis muscle L1-L5 in spasm Rotational Fixation (Type 4 fixation) from L1-L5 - Type IV or IV Push to help remember Can also be done on T11-T12 Assessment Lumbar Assessment (Rotation and Lateral Flexion) Lateral Flexion - SP moves away from testing side (Abnormal) Rotation - SP moves toward testing side (Abnormal) Patient Position Side posture (Lesion side UP) Side lying with minimal torso rotation Maintain spine and pelvis at 90 degrees to the table Pull on the lower arm and fold over the top shoulder stabilizing with the indifferent hand and provide traction superiorly Lower leg slightly bent at the knee Upper leg flexed with upper foot place in the popliteal space (behind knee of lower leg) done to provide rotational traction Pelvis must remain at 90 degrees to the table (perpendicular to take) Practitioner Fencer (lunge stance) Position Pelvis of the doctor is level with the affected spinal segment Bent upper leg of the patient between the Practitioner’s thighs Practitioner performs a thigh to knee contact with patient Practitioner’s torso should not rotate and spine should be straight The forward leg carries the majority of the practitioner’s body weight Contact Point Contact Hand: Forearm resting on patient’s ileum and gluteal muscles pulling ileum towards the practitioner Fully flex and ulnar deviate wrist with Index and Middle Finger contact against affected SP with a fully enforced arch (L1-3) OR Fully flex the wrist with Index and Middle Finger or Middle Finger and Ring Finger contact against affected SP with a fully enforced arch (L4-5) Indifferent Hand: On superior shoulder holding patient’s lower arm and providing superior traction Joint slack Remove joint slack with contact hand by pressing against the Spinous Process and adding enough hip flexion and upper body traction Line of Drive (L1-L3) Inferior to Superior (45 Degree angle) (L4-L5) Lateral to Medial (Perpendicular to table) Thrust Leg and body drop on the patient while the contact hand is on the affected SP: L1-L3 Thrust: Thrust is inferior to superior (45 degree angle) on the spinous process L4-L5 Thrust: Thrust is perpendicular to the spinous process Contraindications Spondylolisthesis and Acute lumbar disc lesion (herniation) HAND POSITIONING