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Joint Manipulation: Lumbar Spine, Sacroiliac Joint and Pubic Symphysis Audio

Joint manipulations for the lumbar spine, sacroiliac joint, and pubic symphysis. Types of manipulations, manipulations vs. mobilizations of the spine, lumbar spine, SI joint, and pubic symphysis. Optimal intervention for anterior pelvic tilt, low back pain, inadequate forward lean, asymmetrical weight shift, sacroiliac joint dysfunction, knee bow in, knee bow out, and hip symmetry. The risk of adverse events, accuracy vs sensitivity, screening, reliability, and validity of lumbar spine, SIJ, and pubic symphysis manips.

Joint Manipulation: Lumbar Spine, Sacroiliac Joint and Pubic Symphysis

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This course describes joint manipulation techniques for the lumbar spine, sacroiliac joint (SIJ), and pubic symphysis. Various synonyms and definitions have been used to describe the term "manipulation". The Brookbush Institute uses one conventional definition of the term "manipulations;" implying low-amplitude (relatively small motions), high-velocity (quick) techniques, intended to target and reduce the stiffness of specific joints or segments, that exhibit a decrease in passive accessory range of motion (a.k.a. stiffness during arthrokinematic motion; specifically glide). Research does imply that manipulations affect multiple joints simultaneously; however, the Brookbush Institute asserts that efforts to target the stiffest joints or segments will increase the likelihood that the stiffest segments are included in the "multiple joints" affected.

The Brookbush Institute has carefully selected manipulation techniques with the intent to increase the probability of practitioner success. That is, techniques have been chosen that are relatively easy to teach, reliably improve outcomes, and are the most commonly used. The Brookbush Institute does not wish to assert that these manipulation techniques are the only techniques that are effective, and/or that these are the best techniques for every outcome measure. It is possible that a highly complex, and/or advanced technique, may result in better outcomes, or that a particular pathology is better addressed with a rarely used technique.

Note, that the term "mobilization" is reserved for low-velocity techniques that are taught in a separate set of courses.

This course includes manipulation techniques that intend to reduce excessive stiffness of the lumbar spine (low back), SIJ, and the pubic symphysis (lumbopelvic manipulations), improve spine range of motion (ROM), improve lumbopelvic alignment, and potentially reduce hip dysfunction. For example, research has demonstrated a correlation between asymmetrical SIJ stiffness, asymmetrical hip range of motion, and a correlation between low back pain, and future lower extremity injury. These techniques may also be used in an integrated approach for improving 

lumbopelvic hip complex dysfunction (LPHCD)

 including sacroiliac joint pain (SIJD), lumbar radiculopathy, iliotibial band syndrome (ITBS), femoroacetabular impingement (FAI), patellofemoral pain syndrome (PFPS), etc. Additionally, due to the relationship between lumbopelvic alignment and hip mobility, and the relationship between hip mobility and ankle motion during gait, these techniques may aid in the treatment of pes planus, Achilles tendinopathy, and plantar fasciitis.

The techniques in this course are recommended for all clinical human movement professionals (physical therapists, physical therapy assistants, athletic trainers, massage therapists, chiropractors, occupational therapists, etc.) to develop an evidence-based, systematic, integrated, patient-centered, patient-centered, and outcome-driven approach.

Sample Intervention: Left Asymmetrical Weight Shift

Joint Manipulation: Lumbar Spine, Sacroiliac Joint, and Pubic Symphysis

Joint Manipulation: Elbow (Radial Head) and Wrist

Joint Manipulation: Ankle, Midfoot, and Tibiofibular Joint

For an introduction to joint mobilizations and manipulations:

Joint Mobilization and Manipulation: Introduction

Joint Mobilization and Manipulation: Reliability

Joint Mobilizations and Manipulations: Effects

Joint Mobilization and Manipulation: Risk of Adverse Effects

Joint Mobilizations and Manipulations: Evidence-based Teaching and Learning

Course Description:  Lumbar Spine, Sacroiliac Joint, and Pubic Symphysis Joint Manipulation

Hip Internal Rotation Goniometry in Prone

Hip Internal Rotation Goniometry in Supine

Hip External Rotation Goniometry in Prone

Hip External Rotation Goniometry in Supine

Gluteus Maximus Manual Muscle Testing (MMT)

 - Weak or With Compensation (Lumbar extension and/or knee flexion)

Gluteus Medius Manual Muscle Testing (MMT)

 - Weak or With Compensation (Lumbar lateral flexion and/or hip flexion)

Introduction

Sacroiliac Joint (SIJ) Manipulation Summary:

Research Summary

Lumbar Pain

Comparing Manipulation to Other Interventions

Combining Manipulations with Other Interventions

Comparing Manipulation and Mobilization Techniques

Kinematics of Manipulation

Systemic Effects of Manipulations

Adverse Events

Research Corner: Lumbar Spine Manipulation

Does Sacroiliac Joint (SIJ) Dysfunction Contribute to Low Back Pain?

Sacroiliac joint (SIJ) manipulation is a controversial topic, primarily due to false notions regarding SIJ motion and SIJ assessment. Several studies have used injection to demonstrate that SIJ dysfunction contributes to low back pain. In a study by Fortin et al. on asymptomatic individuals, injection into the SIJ immediately revealed an area of buttock hyperesthesia extending approximately 10 cm caudally and 3 cm laterally from the posterior superior iliac spine (Fortin area) (127). In a follow-up study, 16 patients were selected whose pain most closely matched the "Fortin area", of these patients 10 benefited from therapeutic injection (128). Van der Wurff et al. mapped the area and intensity of chronic low back pain patients and then compared responder and non-responders to double diagnostic SIJ injection. The findings suggest that there were no significant differences in area; however, the intensity of specific areas did differ; with 100% of SIJ injection responders exhibiting more intense pain in the "Fortin area" and only 10% of SIJ injection responders with more intense pain at the ischial tuberosity (129). Maigne et al. demonstrated that nearly 20% of individuals with low back pain and diagnosed SIJ dysfunction, experienced at least temporary relief from fluoroscopic guided SIJ anesthetic block (130). Slipman et al. demonstrated that fluoroscopic guided injections effectively reduced pain, disability, and increased time at work during a 2-year follow-up of patients diagnosed with SIJ dysfunction (131). Soneji et al. demonstrated no significant difference between ultrasound-guided and fluoroscopy guided SIJ injections, with both resulting in a significant reduction from baseline mean pain scores, as well as improvements in physical functioning, discomfort, opioid utilization, and patient satisfaction (132). Although more research is needed to aid in refining assessment and injection interventions, the effect of SIJ injection on low back pain provides strong evidence that SIJ dysfunction is a significant contributor to low back pain.

Sacroiliac Joint Motion

Testing

SIJ Manipulations

Comparing Manipulation Techniques

Systemic Response to SIJ Manipulation

Research Corner: Sacroiliac Joint 

The technique taught in this course is commonly observed in practice; however, there is almost no research on pubic motion or this technique. Garras et al. demonstrated that single-leg stance resulted in pubic motion of 1.4 mm of motion in men, 1.6 mm in nulliparous (never given birth) women, and 3.1 mm in multiparous women (233). Note these values are similar to the amount of motion described for the sacroiliac joint. Considering each innominate is one solid structure, the pubic symphysis and sacroiliac joint must move together, and similar motion may have been expected. An RCT by Hensel et al. demonstrated that pregnant women in their 3rd trimester benefited from an integrated plan of care, including conventional physician care and 12 osteopathic techniques - including the shotgun pubic symphysis manipulation taught below. The integrated care plan resulted in significantly less low back pain than standard care, slower deterioration of low back pain function, no increase in the number of patients who experienced complications; however, there was no impact on outcome measures related to labor itself (234). Considering that the shotgun pubic symphysis manipulation was one of 12 techniques, it is impossible to determine the technique's contribution to the outcome. Although the amount of research on the pubic symphysis and manipulation is less than ideal, it may be reasonable to suggest that it supports the plausibility of its effective implementation.

In practice, pubic manipulation is most often attempted when SIJ dysfunction has been confirmed, and SIJ techniques alone do not completely resolve symptoms. However, certain symptoms may specifically indicate pubic manipulation. Subjective symptoms specific to pubic symphysis dysfunction include 

 tendonitis or pain, and symptoms similar to femoral acetabular impingement (FAI). Pubic symphysis caudal and cranial mobilizations may be used to aid in the assessment of stiffness via palpation; however, this is a sensitive region for the patient, and the technique may have limited reliability. In summary, research suggests that the effective inclusion of pubic symphysis shotgun manipulation is plausible; however, the limited amount of research results in reliance on clinical outcomes.

Pubic Symphysis Manipulation

Lumbar Manipulation

Sacroiliac Joint Chicago Technique Manipulation

Shotgun Manipulation (Pubic Symphysis)

Video Demonstration

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Anuario Jurídico y Económico Escurialense

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Aspinall, S. L., Jacques, A., Leboeuf-Yde, C., Etherington, S. J., & Walker, B. F. (2019). No difference in pressure pain threshold and temporal summation after lumbar spinal manipulation compared to sham: A randomised controlled trial in adults with low back pain. 

Dishman, J. D., & Bulbulian, R. (2000). Spinal reflex attenuation associated with spinal manipulation. 

Dishman, J. D., Burke, J. R., & Dougherty, P. (2018). Motor Neuron Excitability Attenuation as a Sequel to Lumbosacral Manipulation in Subacute Low Back Pain Patients and Asymptomatic Adults: A Cross-Sectional H-Reflex Study. 

Dishman, J. D., Dougherty, P. E., & Burke, J. R. (2005). Evaluation of the effect of postural perturbation on motoneuronal activity following various methods of lumbar spinal manipulation. 

Dishman, J. D., Cunningham, B. M., & Burke, J. (2002). Comparison of tibial nerve H-reflex excitability after cervical and lumbar spine manipulation. 

Dishman, J. D., & Burke, J. (2003). Spinal reflex excitability changes after cervical and lumbar spinal manipulation: a comparative study. 

Colloca, C. J., Keller, T. S., & Gunzburg, R. (2004). Biomechanical and neurophysiological responses to spinal manipulation in patients with lumbar radiculopathy. 

Cao, D. Y., Reed, W. R., Long, C. R., Kawchuk, G. N., & Pickar, J. G. (2013). Effects of thrust amplitude and duration of high-velocity, low-amplitude spinal manipulation on lumbar muscle spindle responses to vertebral position and movement. 

Sung, P. S., Kang, Y. M., & Pickar, J. G. (2005). Effect of spinal manipulation duration on low threshold mechanoreceptors in lumbar paraspinal muscles: a preliminary report. 

Pickar, J. G., & Kang, Y. M. (2006). Paraspinal muscle spindle responses to the duration of a spinal manipulation under force control. 

Floman, Y., Liram, N., & Gilai, A. N. (1997). Spinal manipulation results in immediate H-reflex changes in patients with unilateral disc herniation. 

Bibliography

Questions, comments and critiques welcomed and encouraged

Joint Manipulation: Lumbar Spine, Sacroiliac Joint and Pubic Symphysis

Related Courses:

Course Description: Lumbar Spine, Sacroiliac Joint, and Pubic Symphysis Joint Manipulation

Introduction

Research Summary

Research Corner: Lumbar Spine Manipulation
7 Sub Sections

Research Corner: Sacroiliac Joint
6 Sub Sections

Pubic Symphysis Manipulation

Video Demonstration
3 Sub Sections

Bibliography

Related Courses:

Comments

Guest

Joint Manipulation: Lumbar Spine, Sacroiliac Joint and Pubic Symphysis

Related Courses:

Course Description: Lumbar Spine, Sacroiliac Joint, and Pubic Symphysis Joint Manipulation

Introduction

Research Summary

Research Corner: Lumbar Spine Manipulation7 Sub Sections

Research Corner: Sacroiliac Joint 6 Sub Sections

Pubic Symphysis Manipulation

Video Demonstration3 Sub Sections

Bibliography

Related Courses:

Comments

Guest

Research Corner: Lumbar Spine Manipulation
7 Sub Sections

Research Corner: Sacroiliac Joint
6 Sub Sections

Video Demonstration
3 Sub Sections