Lumbar Lab

Lateral Shift in Patients with HNP

  • Definition of Lateral Shift:

    • A lateral shift is described as the position of the shoulders, which typically shift away from the painful side as a compensatory mechanism.

  • Correction Techniques:

    • Lateral Shift Correction (Side Glide in Standing)

    • Self-Correction by Patient:

      1. Patients attempt to reposition their hips under their shoulders while moving away from the painful side (RSGIS).

    • If Unable to Self-Correct:

      • Manual correction by the Physical Therapist (PT):

      • Setup: PT either sits or stands on the side of the lateral shift, encircles the patient’s hips with arms, and places a shoulder on the patient’s shoulder (a pillow is acceptable for comfort).

      • Procedure: Maintain pressure on the patient’s shoulder, pulling the patient’s hips toward the PT for 10 repetitions with a brief hold to monitor peripheralization or centralization of symptoms.

      • Additional Exercise: Incorporate lumbar spine extension while maintaining the corrected position.

    • References: Stetts & Carpenter, page 159-160 provides additional detail on corrections for right lateral shift.

Lateral Shift Correction in Prone Position

  • Approaches:

    • A) Physical Therapist assists the patient in shifting hips to the non-painful side.

    • B) The PT maintains hips off center either for Repeated Extension Involvement Loading (REIL) or for Posterior-Anterior Mobilization (PA mob).

Repeated Motion Testing Techniques

  • Focused on identifying better, worse, or unchanged symptoms.

  • Exercises Included:

    • Flexion Techniques (RFIS, RFIL): 10 repetitions in various positions (do not stop after 3 reps).

    • Standing

    • Hooklying – double knee to chest (DKTC)

    • Extension Techniques (REIS, REIL):

    • 10 repetitions in various positions (do not stop after 3 reps).

    • Variants:

      • Prone on a pillow

      • Prone without a pillow

      • Prone on elbows

      • Prone press-up

    • Lateral shift by shifting hips to non-painful side during:

    • Standing: 10 repetitions

    • Prone: shift hips away from pain, REIL.

    • Note: If excessive pain occurs in standing positions, non-weight bearing (NWB) positions should be selected. Confirm directional preference in multiple positions.

Exercise Progression

  • Flexion Progression:

    • Start from hook lying to DKTC, progressing through different positions while ensuring 10 repetitions every 2-3 hours.

  • Extension Progression:

    • Involves various prone variations, including:

    • Prone on pillow

    • Prone without a pillow

    • Variations of prone press-ups, including those with exhalation, overpressure (OP), and using a belt.

Joint Play and Mobilizations

  • Types:

    • Passive Physiological Intervertebral Motions (PPIVMs):

    • Includes flexion, extension, side bending (SB), and rotation all performed in side lying.

    • Passive Accessory Intervertebral Motions (PAIVMs):

    • Performed in prone, focusing on central PA and unilateral PA (targeting facets ~2-3cm from the spinous process).

Special Tests for Lumbar Dysfunction

  • Lumbar Quadrant Test:

    • Patient stands and actively moves into:

    • Extension

    • Side bend ipsilateral to pain

    • Rotation ipsilateral to pain

    • Cue: “Reach back as though you’re trying to touch the back of your knee.”

    • Implications:

    • Local pain suggests facet dysfunction, degeneration, or stenosis.

    • Radicular pain indicates nerve root compression.

Pain Assessment Tests

  • Spring Test: Assess local mobility dysfunction.

  • Prone Instability Test:

    1. Start with feet on the floor, perform central PA at the suspected unstable level and note pain.

    2. Patient lifts feet off the floor (< 6 inches) while PT performs central PA.

    3. Positive test indicated if pain from the first part of the test improves or disappears in the second part.

Slump Test

  • For General Lower Extremity Neurological Testing:

    • Patient sitting with thighs supported, knees together, hands behind back.

    • Procedure:

    • The patient slumps (without neck flexion), adds overpressure (OP), flexes neck, extends knee actively, and dorsiflexes ankle.

    • If symptoms occur, release neck flexion.

Sciatic Nerve Testing

  • Straight Leg Raise Test (SLR):

    • Patient is passively lifted at the lower extremity (LE) maintaining neutral hip rotation and knee extension.

    • Note angle of hip at symptom onset or resistance onset. Sensitizations include:

    • Ankle dorsiflexion

    • Hip internal rotation, adduction

    • Neck flexion.

    • A positive result typically appears between 30-70° hip flexion.

  • Contralateral Symptoms:

    • Considered positive if symptoms appear on the opposite side (known as Crossed SLR).

Femoral Nerve Testing

  • Prone Knee Bend Test:

    • Patient prone with neutral hip; test involves passive knee flexion.

    • Sensitization added through hip extension or ankle plantar flexion.

  • Side Lying Variation:

    • The patient partially flexes hip while supported, and has knee flexed to 90°. Note symptoms during passive hip extension.

Nerve Mobilization Techniques

  • Types Include:

    • Glides, Sliders, Flossing: Addressing neural tension through various movements in different positions.

Trunk Endurance Tests

  • Flexors and Extensors Testing:

    1. Flexors: Start trunk supported at 55 degrees, hold unsupported (record time).

    2. Extensors: Lying prone, lift trunk to horizontal while holding (record time).

    3. Side Plank: Variants performed and time recorded.

  • Abdominal Brace vs. Abdominal Drawing-in Maneuver (ADIM):

    • AB (Abdominal Brace):

    • 5-10% max isometric contraction of trunk muscles.

    • No preferential activation.

    • No spine or pelvis motion.

    • “Brace as though someone is going to punch you in the stomach.”

    • ADIM:

    • Focuses on transverse abdominus and multifidi.

    • Performed in hook lying with relaxed breathing.

    • Draw in navel toward spine and hold while breathing normally.

Core Training Insights

  • Combining Both Techniques:

    • AB provides dynamic stability of the spine.

    • ADIM better focuses on segmental motor control involving local core stabilizers.

  • McGill’s Big 3 Exercises Include:

    1. Bird Dog

    2. Side Plank

    3. Modified Curl up.

Clinical Prediction Rule for Lumbar Spine Manipulation

  • Criteria for effective manipulation:

    1. Pain duration < 16 days

    2. Pain proximal to knee

    3. Internal hip rotation greater than 35 degrees

    4. Hypomobility in one or more lumbar segments

    5. FABQ work subscale score < 19

  • Achieving 4 out of 5 criteria provides a success rate of 95% for improvement as per Oswestry Disability Index.

  • References for this rule include: Flynn et al. (2002), Cleland et al. (2006).

Techniques for Joint Mobilization/Manipulation

  • Include several methods:

    • Central PA procedures for sacrum and lumbar spine.

    • Unilateral PA for sacroiliac joints and lumbar spine.

    • Techniques such as sacral inferior glide/distraction and various forms of side lying rotation or flexion manipulation.

Concluding Notes

  • Sacral Inferior Glide and Lumbar Mobilization:

    • Techniques practiced can also include lumbar mobilization in both supine and side lying positions, often used to improve mobility and alleviate symptoms.