Kins 724: Lumbar Back

biomechanics

the motion segment consists of 2 adjacent vertebrae

• intervening disc

• associated articular facet joints

• ligamentous structures

• should also consider structures in the vertebral canal and intervertebral foramen

intervertebral motion is described in relation to motion of the superior vertebra upon the inferior vertebra

movements possible at each lumbar motion segment are: sagittal (flexion/extension), frontal (lateral flexion), horizontal/transverse (axial rotation) planes

• additional motions include anterior/posterior translation, anterior/posterior tilt and distraction/compression

how many degrees of freedom

6

facets

superior articular facets face posterior and medial

inferior articular facets face anterior and lateral

the orientation of the lumbar facet joints significantly restricts the quantity of rotation available in the lumbar spine

quality of translation= health of lumbar spine

flexion- biomechanics

the superior articular surfaces bilaterally glide up and forward on the inferior articular surface

opening facets

extension- biomechanics

the superior articular surfaces bilaterally glide down and backwards on the inferior articular surface

closed facets

rotation - biomechanics

right rotation- left superior articular surface glides down and backwards on the inferior articular facet. the right superior articular surface glides up and forward

right rotation- right side opens, left closes

sidebending

with a right sidebend- ipsilateral (right) superior articular surface glides down and backwards on the inferior articular facet. the contralateral (left) superior articular surface glides up and forward. side bending to is closing, opposite is opening

right side bend- right closes, left opens

coupling

coupled motion is the “phenomenon of a consistent association of a motion along or about one axis, whether it be a translation or a rotation, with another motion about or along a second axis. the principal motion cannot be produced without the associated motion occurring as well”

coupled motion can also be defined as the motion that occurs in directions other than the direction of the load applied. the most consistent pattern involves an association between rotation and sidebending in all areas of the spine

coupling will occur opposite in lumbar segments

• from a neutral starting position, sidebending at L3-4 will occur concomitantly with contralateral rotation of L3 on L4

facet joint dysfunction

• lumbar vertebrae articulate anteriorly via the intervertebral disc and posteriorly by the paired facet joints

• when a facet joint becomes symptomatic, hypertonicity is often detected through palpation of the superficial musculature medially adjacent to the spinous process

• can be assessed in either seated/standing or prone (best)

• important to assess the motion characteristics of a symptomatic region suspected of facet joint dysfunction, which can often be identified through palpation of the transverse processes.

facet entrapment/impingement

this condition is typically preceded by a sudden-awkward movement that results in acute one-sided discomfort

patients pain pattern and limitation is often comprised of restrictions in extension, ipsilateral side bending, and contralateral rotation

in the lumbar spine- entrapments in the facet joint occur most frequently at L4-5 and may result from torn or separated meniscoid tissue in the facet joint

immediate relief provided by isometric contractions of the multifidi or a gapping technique may support suspicions of capsular entrapment

opening restriction (stuck closed)

in case of a right opening restriction at L4-5:

• hypertonicity and tenderness to palpation will be present

• prominence of the right L4 transverse process in neutral and flexion of the lumbar spine

• this positional fault in conjunction with pain on the right during flexion and/or left sidebending indicates that the right L4-5 facet joint is stuck in extension

  • the patient is unable to move up and forward on the right

closing restriction (stuck open)

in the case of a right closing restriction at L4-L5

• hypertonicity and tenderness to palpation will be present

• prominence of the contralateral (left) transverse prominence in neutral and extension of the lumbar spine

• the positional fault in conjunction with pain on the right during extension and/or right sidebending indicates that the right L4-5 facet joint is stuck in flexion

  • the patient is unable to move down and back on the right

lumbar root syndrome L3

pain distribution

• greater trochanter, distal anterior thigh, medial side of the knee

cutaneous innervation:

• trochanter area, distal anterior thigh, medial side of knee

reflex:

• patellar

myotome:

• quadriceps, psoas major

lumbar root syndrome L4

pain distribution:

• upper lateral gluteal region, lateral side of knee, anterior leg area, medial foot area

cutaneous innervation:

• lateral side of knee, anterior medial leg, medial foot area

reflex:

• patellar

myotome:

• quadriceps, tibialis anterior

lumbar root syndrome L5

pain distribution

• lateral gluteal region, posterior lateral thigh, lateral leg area, anterior foot and first toe

cutaneous innervation:

• lateral leg, anterior foot area, first and second toes

reflex:

• none

myotome:

• extensor hallucis longus, gluteus medius

lumbar root syndrome S1

pain distribution:

• lateral gluteal region, medial posterior thigh, lateral leg area, heel, lateral foot areas, third, fourth, and fifth toes

cutaneous innervation:

• lateral foot area, third-fifth toes

reflex

• achilles

myotome

• peronei, gastrocnemius

S2-3-4

level:

• medial/central prolapse in lumbar region

pain distribution:

• posterior thigh and leg, perineum

cutaneous innervation:

• same

reflex

• none

myotome:

• bladder/rectum

lumbar assessment

articular pain

• facet opening restriction ( no flex, contralateral side bend)

• facet closing restriction (no extension, ipsilateral side bend)

• facet impingement (no extension, ipsilateral side bend, concentric rotation)

treatment approach: from functional area

kicking action- bottom segments then up

throw (overhead) - treat from top down on segments

iliopsoas release

• patient positioned in supine

• therapist positioned on the involved side

• positioned the patients involved hip in 70 degrees of hip flexion and slight abduction

• find the ASIS as your initial landmark. gently sink your fingers down off the ASIS and you will be on the iliacus

  • to palpate the psoas, move slightly more medial/superior to contact the psoas muscle belly

  • to palpate the iliacus- psoas musculotendon junction, move medial/inferior

• to release apply pressure in a perpendicular direction to the muscle fibers

quadratus lumborum (QL) release

• patient positioned in sidelying with the treatment side up

• therapist positioned behind and facing the patient

• position the patients bottom hip and knee in extension and position the top leg in 90 degrees of hip flexion with the leg hanging off the side of the table

• contact the superior aspect of the patients iliac crest with caudal hand

  • weave the cranial hand under the patients top arm to maintain and stabilize the patient’s trunk in slight rotation

• mobilize the iliac crest in an inferior direction to mobilize the vertical fiber of the QL and then in an interior-lateral direction to mobilize the oblique fibers of the QL

multifidus release

• patient positioned in sidelying with the involved side up

• therapist is positioned in front facing the patient

• position the patients bottom leg in extension

• position the top hip in flexion with the knee resting in the therapists abdomen or proximal thigh to be used as the motion lever

• with the caudal hand, palpate the multifidus intersegmentally, flexing the hip more with the thigh and cranial hand as you palpate caudal to cranial

• locate treatment segment and apply pressure with caudal fingers, while simultaneously rocking the knee back and forth to produce an active release

lumbar unilateral anterior glides

indication: improve segmental restrictions

• prone with pillow under lumber spine

• thumb over thumb placement is on transverse process

• apply anteriorly directed force through hypothenar eminence or thumb on superior segment to target segment

lumbar forward bending mobilization

indication: improve segmental forward bending & opening restriction

sidelying, 1/3 of thighs over the edge of table; tibial tuberosities on clinicians ASIS

cephalad hand stabilizes superior vertebra of segment to be mobilized; caudal fingers on spinous- transverse process of inferior segment

while caudal hand provides force & cephalad hand stabilizes, clinician weight shifts to create forward bending

lumbar/thoracic fascial release

Child Pose
• Ipsilateral side arm, angle over
• Forearm is providing stress to spinal erectors,
etc. muscles
• Move arm from Supination to Pronation while
apply tension with other hand to extended
hands.

deep paraspinal release

sidelying away from practioner

find spot to pin in muscle and have them go through active motions

#1 motion:

• arm opens back, flex leg

#2 motion:

• arm opens back, bring knee up

lumbar backward bending - mobs

indication: improve segmental backward bending & closing restriction

sidelying, 1/3 of thighs over edge of table, tibial tuberosities on clinicians ASIS

cephalad hand stabilizes spinous/transverse process of segment to be mobilized: caudal hand maintains flexed knees against ASIS

stabilize superior segment & apply long axis force posteriorly through thigh

lumbar sidebending w/ finger block

indication: improve segmental sidebending restriction

technique 1: prone, pillow under the lumbar spine; finger/thumb on side of superior spinous process of segment to be mobilized; grasp distal thigh

• move clients leg into abduction until movement occurs @ segment to be mobilized; perform prolonged stretch or oscilllations against blocked segment

technique 2: sidelying with 1/3 of clients thighs over edge of plinth and resting on clinicians leg: finger/thumb on side of superior spinous process of segment to be mobilized: grasp ankles

• move clients ankles up and down to induce trunk SB motion up to segment

mobilization to correct an opening restriction on the left

Patient in sitting position with their arms crossed around
shoulders.
• Stand on right side of patient with your right hand grasping their
left shoulder, and your right axilla positioned over their right
shoulder.
• Contact the right side of the spinous process of the superior
vertebrae of the involved segment with your left thumb.
• With your body and right upper extremity, side glide the lumbar spine
away and up to the level, and then flex the trunk down the level. Using
your body weight toward the floor simultaneously mobilize from right to
left with the left thumb on the spinous process up and forward creating
a right rotation.
• Note: Side lying for bottom-up approach (lower lumbar) / Seated for
top down (upper lumbar)
• Following technique: should see immediate improvement (90%+), if

mobilization to correct a closing restriction on the right

Patient in sitting position with their arms crossed around shoulders.
• Stand on right side of patient with your right hand grasping their left
shoulder, and your right axilla positioned over their right shoulder.
• Contact the right side of the spinous process of the superior vertebrae
of the involved segment with your left thumb. For a more direct
technique, contact the right side of the inferior facet. Location will
depend on patient irritability.
• With your right upper extremity, initiate backward bending, right side
bending, and right rotation to the patient’s trunk down to the level.
• Using your body weight toward the floor simultaneously mobilize
from right to left with the left thumb on the superior subspinous
process. If selecting the more direct technique, stabilize the right facet
of the inferior segment in an anterior/superior direction.

lumbar rotation with finger block

indication: improve segmental rotation restriction

technique #1: prone, pillow under lumbar spine; fingers/thumb on superior spinous process of segment to be mobilized

• grasp legs & impart rotatory force through pelvis until movement occurs @ segment to be mobilized; perform prolonged stretch or oscillations against blocked segment

technique #2: sitting with inferior thumb on side of inferior spinous process of segment to be mobilized

• with clinicians hand woven through clients arm, ipsilateral trunk rotation is performed

lateral shift correction

using segmental movements, the clinician glides the thoracic spine in the opposite direction as he/she pulls the pelvis