Lumbar Techniques

Lumbar Objective Assessment: Observation

Guarding habits

Resting posture - sitting and standing

Listing (lateral shift) to either side

Lumbar Objective Assessment: Functional Assessment

Gait

Sit-stand

Calf-raise / walks on heels (if concern for low lumbar radiculopathy)

Lumbar Objective Assessment: AROM

Flexion / extension

Side flexion

Rotation (seated)

Repeated movement assessment (McKenzie directional preference)

Lumbar Objective Assessment: Palpation

Central, paraspinal, QL, Thoracolumbar fascia

Lumbar Objective Assessment: Neurological Screening (if indicated)

Lower limb neurological assessment of dermatomes, myotomes and reflexes (AJ and KJ)

Lower limb neurodynamic assessment (slump/PSLR)

Upper motor neuron screening: clonus, babinski, Hoffmans

Lumbar Objective Assessment: Passive ROM (PPIVM Ax)

Flexion/extension PPVIM

Side flexion / rotation PPIVM

Lumbar Objective Assessment (PAIVM Ax)

Central and Unilateral Pa Glide

Lumbar Objective Assessment: Special Tests

Tests of lumbar instability (prone instability test and shear)

SIJ Cluster Test

Observation of Habitual Posture

1. understand relaxed habitual resting posture in standing (march on sport eyes closed) and sitting

2. General classification of lumbar postures:

• Normal

• Swayback (passive extender)

• Increased lordosis (active extender)

• Flat back (post pelvic tilt)

3. Ask patient to self correct - “I want you to show me what you would do if I asked you to show me ‘perfect posture’

4. Add load (axial)

Observation: Sitting Posture

What to look for:

Anterior/posterior pelvic rotation

Overactive lumbar erector spinae

Forward head posture

Poor proprioceptive awareness (ask them to correct)

Poor muscle tone

Listing - side shift

Lateral spinal curvature seen in standing

Adaptation usually to acute nerve root compression

Pelvic shift will occur to de-load nerve root and affected leg

Will generally self-resolve as nerve irritation subsides

Functional Assessment

Generally ask the pt. to do a functional task they have some difficulty doing (not too pain provocative)

Functional Assessment Suggestions

Sit to stand

• looks at glute max function

• bias of one leg?

Hip F in standing

• dissociation of lx spine and hip movement

Back against wall

• ability to relax lumbar lordosis in standing

Find neutral in sitting

• are they able to find a neutral spine posture

• go to end of range lordosis, reverse, then find middle

Sitting hip flexion

• dissociation of lx spine and hip movement

Walk on heels/toes

• if any concern for low lumbar radiculopathy (tests DF (L4), EHL (L5), and PF (S1)

Spinal Movements: AROM

Flexion

Extension

Lateral flexion

Rotation (in sitting- locks pelvis in place)

+as indicated

• pelvic tilt

• pelvic shift

• combined movement

  • Ext / LF

  • Quadrant test

Palpation

Should be level specific and looking for pain provocation or any areas of muscle spasm/hypertonicity

Palpation Sequence

1. Identify your level

2. Palpate L5/S1 both centrally + unilaterally

3. Palpate SIJ bilaterally

4. Find L4/L5 again and then work superiorly up to T12 - centrally, then paraspinally both sides

5. Check lumbopelvic fascia + QL regions more lateral to paraspinal space

6. Check piriformis + sciatic nerve trunk as indicated

Iliac Crest Height

L4/5 interspinous space

When to do Neurological

full lower limb neurological exam including dermatomal sensation, myotomal strength and reflex assessment is indicated in any patient with symptoms referring below the gluteal fold

• clinical setting will dictate the need for a neurological exam even in the absence of the rule above, such as the emergency department where sinister or serious pathology is over 5x more prevalent than primary care/private practice

PPIVM -Techniques

Flexion / Extension

Lateral Flexion / Rotation

PAIVM -Techniques

Central PA

Caudal + Cranial glides

Unilateral PA

McKenzie Repeated Movements Procedure- Techniques

Extension

Lateral Shift

Tests of Instability- Techniques

Prone Instability Test

Shear Test

Traction / Distraction - Techniques

Longitudinal Traction

Mobilisation with Movement - Techniques

SNAG into flexion (4pt kneel)

Seatbelt SNAG into extension (sitting)

High Velocity Thrust (HVT)- Techniques

Rotation HVT

Flexion / Extension PPIVM - Aim

Assessment: to assess interspinous movement (hyper/hypo) or pain provocation at a level of interest

Treatment: to assist in restoring pain free flexion / extension AROM

Flexion / Extension PPIVM - Procedure

Side lying

Palpate interspinous space between 2 SP’s using proximal hand

Cradle patients knees on your thigh/hip

Sideways lunge to the left and right to create lumbar flexion and extension

Repeat as you move down the lumbar spine across the levels of interest

Rotation / Lateral Flexion PPIVMS- aims

Assessment: to assess interspinous movement (hyper/hypo) or pain provocation at a level of interest

Treatment: To assist in restoring pain free flexion/extension AROM

Rotation / Lateral Flexion PPIVMS- Procedure

Palpate interspinous space between 2 SPs using proximal hand

Position the lumbar spine into neutral flexion / extension

Using your forearm over the iliac crest, create a rotation at the lumbar spine, using the proximal arm to stabilise the trunk and palpate interspinous movement

Repeat as you move down the lumbar spine across the levels of interest

PAIVMS- Central PA Glide Aims

To assess interspinous movement (hyper/hypo) or pain provocation at a level of interest

Treatment: To assist in restoring pain free AROM

PAIVMS- Central PA Glide - Procedure

Using the C Grip and hypothenar eminence contact point

Take up soft tissue slack and position hypothenar eminence over the spinous process of the level being assessed/treated

Use a gentle bodyweight shift to create accessory motion at the vertebral level

Assess the levels above and below for reactivity/pain and/or hypo or hypermobility relative to the segments directly above and below

PAIVMS- Central PA Glide - Cephalad and Caudad Bias- Aims

To assess interspinous movement (hyper/hypo) or pain provocation at a level of interest

Treatment: To assist in restoring pain free flexion (ceph) or extension (caud) AROM

PAIVMS- Central PA Glide- Cephalad and Caudad BIAS - Procedure

Prone

Using the ‘C’ grip and hypothenar eminence contact point

Take up soft tissue slack and position hypothenar eminence over the spinous process of the level being assessed/treated

As per previous – alter your body position and direction of force to create a gentle PA movement with either a ceph or caud bias

Use a gentle bodyweight shift to create PA movement with directional bias

PAIVMS- Unilateral PA Glide- Aims

To assess interspinous movement (hyper/hypo) or pain provocation at a level of interest

Treatment: To assist in restoring pain free AROM for extension, LF or rotation

PAIVMS- Unilateral PA Glide- Procedure

Prone

Position the flattest part of both thumbs over the transverse process / facet joint of the lumbar spine level of interest

With extended elbows and large thumb contact areas (as flat as possible with the pad of thumb) gently create a localised PA glide using bodyweight shifting to generate the motion

Assess for reactivity/pain provocation, or relative hyper or hypomobility of that segment compared the surrounding levels

McKenzie Repeated Movements - Aims

Assessment: To determine if repeated movement creates a centralisation phenomenon of patient’s referred leg symptoms

Treatment: To improve pain free motion within the lumbar spine for those with derangement syndrome

McKenzie Repeated Movements - Procedure

Ensure you have a good idea of the patient’s baseline symptoms

Perform the usual active movement (F/E/LF) or a movement to correct an adaptive postural fault (e.g lateral shift/list)

Guide repeated movement x10 reps, slowly

Ask patient regarding their resting symptoms after each repeated movement in each direction – we are looking for the movement direction that induces centralisation of symptoms (this direction is the ‘directional preference’)

You can then use this directional preference to guide treatment (e.g McKenzie repeated ex’s – prone extension 3x6 reps)

Prone Instability Test - Aims

Assessment: To determine if activation of the lumbar paraspinal musculature during PA movement of the spine reduces pain provocation (thereby indication possible instability)

Prone Instability Test - Procedure

Prone, hips at edge of plinth, feet on floor

Ask patient to lie and hold themselves onto the plinth as photographed here (hip joint able to flex off end of plinth)

Firstly provide a PA glide in this position with the patient completely relaxed and assess pain provocation at the level of interest

Secondly, ask the patient to now lift both feet off the ground slightly (to engage the lumbar extensors) and perform the same PA glide to the same level as tested earlier

A positive test would be a reduction in pain during the second test (with lumbar extensors engaged)

Instability- Shear Test - Aims

Assessment: To assess for hypermobility in an AP direction at a single intervertebral level

Instability- Shear Test - Procedure

Side lie, knees and hips flexed to ~90deg

Position yourself and your patient in neutral lumbar flexion/extension at the level of interest

Rest the patient knees on your distal thigh as you would for a lumbar flexion/extension PPIVM

Bring both hands to the spinous processes of the level in which you are assessing (e.g SP L4 and L5 for a suspected L4/5 instability)

Now push your patient’s femurs in an AP direction with your thigh to create an AP glide at that level

A positive test would be hypermobility of that segment compared to the surrounding levels, and/or pain provocation with this movement

Maitland Manual Therapy Techniques

Application: Oscillating, take up soft tissue slack first

Grade: Grade 1 (pain relief only) to Grade V (high velocity thrust)

Duration: Generally safest to start approx. 30secs at a single level and grade, then re-assess your key objective measure

Sets/Reps: 3 to 4 sets within one session would be appropriate for who is demonstrating in-session improvements in pain and/or movement range

Duration of PPIVMs and PAIVMs

Generally safest to start approx. 30secs at a single level and grade, then re-assess your key objective measure

Sets/Reps of PPIVMs and PAIVMs

3 to 4 sets within one session would be appropriate for who is demonstrating in-session improvements in pain and/or movement range

Longitudinal Lumbar Traction- Aims

Treatment only: To provide longitudinal traction (global) to the lumbar spine, typically used to relieve radicular pain caused by nerve root compression

Longitudinal Lumbar Traction- Procedure

Supine

Gently lift the patient’s leg, and support it with both hands either at the ankle or above the knee (above knee useful for those with knee pain)

Assume a lunge position and grip the leg with your forearm against the body as well as hands

Transfer your weight onto the back foot of your lunge stance, thereby creating a longitudinal traction force on the leg

Maintain this position for usually up to 30secs should appropriate relief be achieved with this position

Very gently release the traction as often there is an increase in pain on release as compressive load is returned to the nerve root, causing a sharp increase in radicular pain

SNAG - Flexion MWM- Aims

Treatment only: To assist in restoring pain free flexion motion in an intervertebral segment

SNAG - Flexion MWM - Procedure

4pt kneel moving into childs pose

Contact spinous process to be mobilised using hypothenar eminence (relaxed)

Support patient underneath abdomen to control movement and counterpressure

Apply glide in PA and cephalad direction (mostly ceph)

Ask patient to actively rock back into a child’s pose position

Return to start position, release glide

SNAG - Extension MWM - Aims

Treatment only: To assist in restoring pain free extension motion in an intervertebral segment

SNAG - Extension MWM - Procedure

Seated with arms crossed

Contact spinous process to be mobilised using hypothenar eminence (relaxed)

Support patient on one shoulder to control movement and provide some counterpressure

Apply glide in PA and cephalad direction (mostly ceph)

Ask patient to actively extend into increased lumbar lordosis

Return to start position, release glide

High Velocity Thrust - Rotation- Aims

Treatment only: To provide longitudinal traction (global) to the lumbar spine, typically used to relieve radicular pain caused by nerve root compression

High Velocity Thrust - Rotation- Procedure

Supine

Gently lift the patient’s leg, and support it with both hands either at the ankle or above the knee (above knee useful for those with knee pain)

Assume a lunge position and grip the leg with your forearm against the body as well as hands

Transfer your weight onto the back foot of your lunge stance, thereby creating a longitudinal traction force on the leg

Maintain this position for usually up to 30secs should appropriate relief be achieved with this position

Very gently release the traction as often there is an increase in pain on release as compressive load is returned to the nerve root, causing a sharp increase in radicular pain