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Lumbar Spine Anterior to Posterior Mobilization
Lumbar Spine Anterior to Posterior Mobilization is a manual therapy technique that utilizes gentle, hands-on pressure and movement of the spine in order to reduce stiffness, tension, and pain while promoting better range of motion. This treatment can help alleviate chronic pain in the lower back and aid in improving the overall condition of the lumbar muscles and tissue.
Transcript
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This is Brent of the Brookbush Institute, and
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in this video we're going to go over a
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joint based manual therapy technique. If you're watching this video I'm assuming
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you're watching it for educational purposes, and that you are a licensed
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professional with joint based techniques within your scope. That means osteopaths,
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chiropractors, physical therapists you're probably all in the clear. Physical
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therapy assistants, athletic trainers, massage therapist you need to check
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with your governing body in your state or region to see whether this is within
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your scope of practice. Personal trainers this is definitely not within your scope
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of practice. Of course all professions could use this video for purely
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educational purposes, to help with learning biomechanics, anatomy and of
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course palpation. In this video we're going to do posterior to anterior
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mobilizations for the lumbar spine. That's both unilateral and central PA's.
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I think you are going to find for all of the spine that unilateral PA's or
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UPA's, are the workhorse for our mobilizations of the spine. You're going to
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use those possibly the most frequently. I'm going to have my friend Melissa come
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out, she's going to help me demonstrate. The first thing we're going to talk about of
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course is position. So I'm going to have Melissa lie prone. If Melissa had pain
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in extension I could put a bolster underneath her
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hips, just to give us a little bit of flexion and me a little bit more room to
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be able to do these PA's, without pushing her into a painful range. You guys will
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notice her arms are in a relaxed position, and we have these really nice
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tables at Flex here in New York, and they have the arm drop downs. But if you
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didn't have those, this position is probably fine as long as somebody
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doesn't have a really tight shoulder girdle. Or you can have their arms by
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their sides. The thing you want to keep away from is somebody putting their arms
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up, creating a lot of tension through the latissimus dorsi because their latissimus
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dorsi does cross their lumbar spine. So tension here could
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make your mobilizations a little tougher. You can go ahead and put
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your arms down, arm cradle. The other thing you want to consider is that
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Melissa needs to be low enough on this table, that I can get my chest over her
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spine. So that when my arms are straight, all I have to do is rock my torso to get
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my mobilizations. So in essence I'm using my bodyweight, the weight of
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my torso to do my joint mobilizations and not my hands, like trying to do
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something like this. Alright I see people do that every once in a while, oh
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my gosh you're going to wear out your hands. Or they start trying to tricep
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press down their mobilizations, I think you're going to find it not only
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wears you out, it's almost impossible on bigger patients for the lumbar spine
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because the lumbar spine is pretty strong and stiff to begin with, and I
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think you also find that your forces aren't very consistent. So if you're
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trying to do these nice consistent oscillations at the same depth, with the
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same resistance so that you're consistent and reliable, you're going to
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have a hard time doing this, as opposed to just rocking with your
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bodyweight. So the table is nice and low, Melissa's in a good relaxed position. The
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next thing you probably want to do as a newer manual therapists, new
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to mobilizations which I'm assuming you are for these videos, you
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probably don't want to start by trying to palpate through clothing. Now
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obviously we don't want to move clothing that people are uncomfortable with, but I
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can tell you adding a layer of clothing is just one more layer of stuff that we
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have to try to feel through, and if we're talking about pants, right like if you
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have to try to feel through denim pants forget it. Especially the L4-L5, L5-S1.
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If you're doing SI joint mobilizations, trying to do those joints
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which are already very strong through denim, is going to wear your hands out real
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quick. So what I'm going to do is have Melissa lift her shirt up just above the
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bottom of her rib cage, because by definition her lumbar spine would be
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below her rib cage right. So the 12th rib, our last rib, hooks into our last
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thoracic vertebrae and everything below that is lumbar spine. And then I'm going to
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have her flip the top of her waistband down. So she doesn't have to like pull
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down her pants, she just needs to flip her waistband down a little bit.
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If you have people come in workout clothes, sometimes these yoga pants do
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come up high on females so be aware of that and don't let that
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mess with your palpation. Make sure that you find the top of their iliac crests,
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and that you can kind of get your thumbs down to the sacral base, even if it's
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just tucking under the lip of their pants, that's okay. But you
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definitely need them to be enough out of the way that you can get to the lumbar
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spine without having to push through clothing. So the next thing we should
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probably think about is anatomy. Now if you haven't looked at the lumbar spine in a
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little while, you don't remember how the spinous process and transverse process,
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and where the facet joint is located, and what muscles to work around, I definitely
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suggest a little review. You could start with some of those soft tissue videos we
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did, the static release videos we did. Maybe look at some of the anatomy of
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some of the muscles around the lumbar spine, and I've mentioned in our other
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spine videos buying one of these plaster cast spines is really an invaluable tool.
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I understand that this spine is not the same as Melissa's spine and that the
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proportions are not identical, but you take a huge step forward in testing
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yourself with a plaster cast spine. For example, I am going to find
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my sacral base, and then being able to look down and see if you're on the sacral
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base. Then you can test yourself, for example I want to get on to L4-L5, so I'm going to go
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L5 spinous process, L4 spinous process, fall off just lateral
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and inferior, and sure enough I'm on L4-L5, and I can look down. What you're
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doing when you do that is you're starting to create a visual model up
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here, which is going to help you match to what's underneath the soft tissue here.
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If you don't do that it just takes a little bit more time, because this is
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essentially that with mush on top. Mush being all the soft tissues right,
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and all these lumbar extensors and multifidi, and you got things
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like your quadratus lumborum which are off to the side. If you're
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not really familiar and you haven't been doing a lot of manual
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techniques, it's nice to have that thing just to check things out. Now
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let's talk about some of our first palpations. If I find the bottom of
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my rib cage, and follow those ribs up and just follow that, they kind of come
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at an angle like this, and so I'm going to follow that angle up to that spinous
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process, and then I go down one, that's L1, so L1, L2.
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The spinous process have very flat tops, so what you're going to feel is like
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flat and then there's a little divot, and then that's the next spinous process and
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then a little divot, the next spinous process. So once you find L1 you can
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go L2, L3, L4 and hopefully what you'll do is
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if you test yourself, you'll get to the sacrum which starts to feel like a
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crocodile's back. It has two ridges essentially and it's bumpier,
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it's not so flat with a divot, flat with a divot, it's not that consistent anymore,
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it's just bumpier down here right that's that's sacrum. Hopefully you get to L5
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and then sacrum and you're not like L6, L7, there's there's no L6 on most people.
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Every once in a while you meet somebody with an L6, but that's a pretty rare
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thing to come across. So count your lumbar vertebra, and then maybe the next
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thing you want to try doing is finding the transverse process. Believe it or not
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the lumbar vertebrae are wide, they're like really wide. The transverse
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process are as wide as your fist. So you can get in here like this and I can feel
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like that's bone out there, all the way out there, and I'll show you
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this in the close-up recap. They're wide, they're really wide and
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feel it, you can get L3, after L3 transverse process now that we're on, you
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run into the iliac crest here, and then they start getting hidden.
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So find the transverse process, find the spinous process, and then the next
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challenge would be to try to get your fingers on the facets.
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The facets are going to feel like bumps, a little more than a finger
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width from the spinous process. So if this is my spinous process, I want to go
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a finger width over, and then if we're going this way
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the facet joint that's related to the spinous process that you were just on is
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actually lateral and inferior just a little bit, just a tiny tiny
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bit. Once I am over the top of them, then what I want you to do is
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gently start trying to feel through all the soft tissue and see if
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you can get that joint to move a little bit. It does take a bit of force, it does
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take quite a bit of force. This is one of those things where having a mentor who's
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done this before is a really good thing, because I think people get scared
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pushing on the spine and there's reason to be scared. Obviously we don't want to
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damage anything, we don't want to hurt anybody, but to give you an idea if
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I'm doing a central PA I have to push Melissa pretty hard into the table.
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I'm using quite a bit of my bodyweight to get to the end range of those facets
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that are associated with the L1 segment. How does that feel? Yeah it's a
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significant amount of pressure. So let's let's talk about central PA's now that we
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know transverse process, we know spinous process and we know
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where those facet joints are. Let's start moving down and start talking about
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these different mobilizations. So you could do your central
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PA on the spinous process with two thumbs. You just come
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to either side and do it this way. I don't like to do that and I'll
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tell you why, anytime I can find a technique that doesn't require my thumbs I use
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that technique, because there are techniques where your thumbs are your
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only option and your thumbs will wear out if that's all you ever use. So a lot
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of therapists get themselves into trouble because their IP's of
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their thumb, they start ending up with hyperextension, they can't really get
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stable and it starts causing them a lot of pain in that joint. So for this one I
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like what's called a pisiform hamate or cradle, I think it's called a cradle saddle, a
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saddle grip maybe is the right term. What I do is I put this part of my
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hand right about where your pisiform is, over the spinous process. Now
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that's pretty comfortable for the patient too because I'm pretty much
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just pushing them into the soft tissue of my hypothenar eminence there,
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the mush underneath my pinky finger, and then to use both of my hands,
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I'm going to take this hand and it's going to saddle over the top of my hand like so,
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and now when I get into position I can just use my bodyweight. So you can
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see that, this is what I'm pushing with, but this is where my force
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is coming from, straighten out both my arms and now I can do my central PA's. Now
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I have to admit usually central PA's I don't use unless somebody is super
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stiff. I use these more as a part of my passive accessory motion exams where
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I go, okay please tell me the difference between pressure and pain, and I'll
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push down and what's that, pressure or your symptoms? That's symptoms,
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okay so that's symptoms and then I start moving down. Pressure or symptoms?
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Pressure, pressure, pressure, pressure. Good so we know in her case, or at least we're
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going to take a guess in her case, that most of her pain is coming through that
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thoracolumbar junction, somewhere like the L1 segment.
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So I'm going to want to start thinking about what dysfunction happens there.
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Unfortunately hypermobility is actually a more common at that segment, but the
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next thing to do would be to think do I feel like that segment was hypermobile or
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hypo-mobile. The only way you're going to know that is from experience, and you do
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have to keep in mind that palpation is probably our least reliable assessment.
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So this is one of those situations where I may do mobilizations and then
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immediately retest. Just mobilize that one segment for 30-60 seconds,
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have them get up and see if I can reproduce their pain. If they got better
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than we're on the right track, if they didn't then maybe the segment is hyper-
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mobile we need to start thinking more towards stabilization exercise. So again
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in central PA's just thenar eminence over like this, and then I use this like
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this, and then I'm going to push down to end range if I'm doing an exam, and see where
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pain comes from. But if I was doing mobilizations you know that it's
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50 percent. Alright so first resistance barrier, end of arthrokinematic range which
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is there for her, back off to 50 percent, and then I can either do my grade 3 by
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backing off to the first resistance bearing and pushing down to 50 percent, so
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that's my larger amplitude, but less intense mobilization because I'm backing
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all the way off to essentially no resistance. Or I can get a little bit
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more intense by going right up to 50% or maybe even a little deeper, and staying
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there with small amplitude mobilizations. Alright and then see how that feels, and
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she actually does feel kind of stiff. So I might try this and then see how she
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does, and you can follow this technique all the way down. So what I'll
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do is if I'm trying to do more segments in the spine and test.
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So my pisiform hamate is under the spinous process, I
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just take my two fingers, find the next one down, move, and go, two fingers down, go
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two fingers down, go and you can see I can address the whole spine real quick
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there. Now let's go back to the workhorse technique of UPA's. A lot of
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lumbar spine issues tend to be asymmetrical. You have restriction on
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rotation to one side, or at least one side is more restricted than the other, or
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lateral flexion is more restricted to one side than the other, we start looking
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towards these unilateral posterior to anterior mobilizations, this is why I'm
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going to have to use a thumb over thumb technique. So I'm going to find
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spinous process, now we know in her case her symptoms seem to be coming from
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somewhere around the L1 segment. So maybe I start with L1-L2 facet. Push down,
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find the first resistance barrier, find the end. How are you feeling? m-hmm mm-hmm,
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yep that's that's a little bit of her symptoms. Then maybe I start
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my grade three mobilizations, assuming that it's hypomobility, despite
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the fact that she has pain there it's not pain. I don't run into pain before I
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run into her mobility issues, it's like as I get to the end of her range she
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starts having pain, which tends to be stiffness dominance if you're talking
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about like a Maitland approach. So what I might do is do 10-15 seconds worth of
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this, and then ask Melissa does that feel like it's getting better or getting
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worse? Okay so if it's getting better then I'll keep doing it and then of
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course retest. I could go up, the mobilization technique here is
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the same for T11-T12, T10-T11, it's the same unilateral PA so I could
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go up a couple segments, I could go down a couple segments, I could try the other
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side. Of course I would walk to the other side of the table, but again notice that
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all I had to keep in mind was my anatomy which is this facet is just lateral
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and inferior, if I'm talking L1-L2. If I wanted to go T12-L1 then I have to go
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lateral and up just a tiny bit. I'm keeping thumb over thumb so that I'm
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using both thumbs and I have as much strength in my hands as I possibly can.
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My arms are practically straight and I'm just using the weight of my torso to do
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the mobilization for me, keeping my protocols in mind. Notice I'm not doing
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this, I'm not doing this, that's all really bad technique. In fact for some
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individuals if you wanted to try this, you could use the hand position we
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used on the static release videos, which is dummy thumb in between our inner
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thenar groove applying the force. On some individuals you might be able to get
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your hands into the right position, to not have to use thumbs at all in
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a straight up-and-down position, you're essentially using this as a
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little point that you're then pressing into with this, and sometimes that's a
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little bit more comfortable for individuals. You could try maybe a
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little less specific going off to the side and pressing on the transverse
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process with the pisiform hamate grip, that we just talked about with the
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saddle grip. Keep all this stuff in mind, although it's not as specific as this,
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and I know some of you are thinking well why wouldn't I just use the best
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technique. The truth of the matter is, is you're going to get tired and if your
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thumb's hurt, and it's the end of a long day, and you've had a lot of big
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individuals on your table, or a lot of stiff patients. Or maybe it's the end of
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a long week. Maybe you happen to be the athletic trainer or physical therapist
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for like a football team, and everybody you treat is just a really large human
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being. Keep these other techniques in mind,
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a good technique is better than nothing. Even if it's not, don't let perfect
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be the enemy of the good is essentially what I'm trying to say. Let
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me show you guys just a couple more things here, just some special palpations
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to keep in mind. If you find at the top of the iliac crest right, and you keep
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following down you'll eventually run into the PSIS. If you find the space
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that's between the top of the posterior iliac spine, the PSIS and
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then these spinous process here. What we're on, this is L4
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and L5. You will be able to feel this a lot better than I'm
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showing it to you, but there's a little place in between all of this bone
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mass that you start running into here, and in there is your L4-L5 facet. It
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is definitely worth testing that facet. People forget about that facet.
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People will do all of this stuff because it's easy to access, and then they'll
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forget that they need to get in there and really search for that facet
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specifically. How does that feel? That feels really stiff to me. So she
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doesn't have pain, but maybe she's getting hyper-mobile here because this
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is super stiff, I would check on it. Now the same thing with L5-S1. So find that
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triangular space, that's between PSIS, the top of the posterior iliac
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crest, and the spinous process that's just lateral to it. Find that space and
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then what I want you to do is find the sacral base, and I want you to keep
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feeling up the sacral base until you fall off it and that's L5-S1. And now I
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realize L5-S1 you might have to go a little bit this way, to get that to
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move the way you want it to move. Again these are worth checking. They are the
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two segments most likely to be hypermobile, but they also have a
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propensity to become hypomobile. It just depends on the condition, it's a 50-50
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shot. So if you feel like you have normal or more motion than normal when you
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press into them, then leave them alone because you can definitely make somebody
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worse by making them more hypermobile. But I don't know that I would ever rely
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completely on central PA's without at least checking L5-S1, L4-L5 facet, just
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to make sure everything is in good working order. Alright so stay tuned
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for the close-up recap. Okay for our close-up recap we have the lumbar
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spine, you can see how it's nice and visible here. The first thing that we
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talked about finding was maybe L1 right. We did that by following the last rib up
00:22:4000:22:45
to the spinous process of T12, because the last rib would hook into our
00:22:4500:22:50
last thoracic vertebrae and the next spinous process we feel. Alright so kind
00:22:5000:22:58
of flattish spinous process divot. Spinous process would be our first
00:22:5800:23:03
lumbar spinous process, and then we started by talking about central PA's
00:23:0300:23:07
which you know I told you that you could use your thumbs like so. I put one on
00:23:0700:23:11
either side, don't press down on a spinous process like that, that's
00:23:1100:23:16
very pokey. But if you go this way on just either side of the spinous
00:23:1600:23:18
process, you can notice there's a little bit of skin there in the middle.
00:23:1800:23:21
You could do it that way although that's tougher on your thumbs than you need to
00:23:2100:23:33
be. I would go ahead and put your pisiform hamate spot, right this mush of
00:23:3300:23:38
hyperthenar meat right here, right over the top of the spinous process and then
00:23:3800:23:44
you can saddle it up like this, and then you get just that nice lean with your
00:23:4400:23:51
chest over the top of where you're trying to mobilize, and you can just use your bodyweight,
00:23:5100:23:55
real easy. Of course once we found one spinous process it's real easy
00:23:5500:24:01
to go spinous process divot, next spinous process, spinous process divot
00:24:0100:24:06
next spinous process, spinous process divot next spinous process. Keep in
00:24:0600:24:11
mind the spinous process takes up a lot more space than the tiny
00:24:1100:24:16
little divot in between spinous processes. Now the next thing we talked
00:24:1600:24:23
about finding was your transverse process, which believe it or not come out
00:24:2300:24:31
about this wide, they're really wide. This is me rocking Melissa's lumbar
00:24:3100:24:35
vertebra here, and you can see my hands are, they're
00:24:3500:24:39
a fair amount apart like they're her fist width, not quite my fist width but
00:24:3900:24:45
her fist width apart. Nice big lumbar vertebra with nice wide
00:24:4500:24:50
transverse process, and we can use transverse process to do UPA'S. That is
00:24:5000:24:52
something that you're going to want to consider, especially if your thumbs start
00:24:5200:24:57
getting tired and you need to switch to something like this position, this tends
00:24:5700:25:00
to work a little bit better using a transverse process than trying to
00:25:0000:25:05
get into a facet joint, because once you are looking for a facet joints,
00:25:0500:25:11
and you're falling off that spinous process about a fingers width
00:25:1100:25:17
away you'll feel that bump, you can go this way a little bit and feel a bump.
00:25:1700:25:25
You pretty much have to use your thumbs to fit in there, otherwise this becomes
00:25:2500:25:29
tough. You end up getting multiple segments, not that that's a bad thing
00:25:2900:25:35
providing they're stiff at all those segments, but this is a bit more specific.
00:25:3500:25:41
So we have spinous process, we have transverse process that come all
00:25:4100:25:47
the way out here, and then we could go to facets in here and I'm going to show you
00:25:4700:25:50
this on the other side, although I'm on the opposite side of this individual
00:25:5000:25:56
wouldn't do these mobilizations this way. So spinous process, transverse process is
00:25:5600:26:05
all the way out here, and then the facet is about right there. Alright so I
00:26:0500:26:08
hope that helps you with your proportions a little bit. Now I did show
00:26:0800:26:13
you a couple of special techniques, we have the top of the iliac crest here.
00:26:1300:26:20
In line with the top of the iliac crest is the spinous process of L3-L4. If
00:26:2000:26:25
you go just below the spinous process of L4, so you draw a triangle
00:26:2500:26:33
between that spinous process, the top of the back of the iliac crest
00:26:3300:26:37
here there's this little triangle section that's leading
00:26:3700:26:45
into the bony sacroiliac joint, and the bony PSIS. This little
00:26:4500:26:49
spot of still soft tissue, at the bottom of that is the facet of L4-L5.
00:26:4900:26:54
I would keep that in mind because that's one of those segments that people forget
00:26:5400:26:59
to palpate. They're palpating down, palpating down, palpating down, and then
00:26:5900:27:06
they stop because they either accidentally hit the iliac crest, maybe
00:27:0600:27:09
they were too wide to begin with and they were pressing on transverse process
00:27:0900:27:13
instead of facets. So they get to the iliac crest and they
00:27:1300:27:18
stop. Keep that L4-L5 facet in mind, and then the other thing I want you
00:27:1800:27:22
to do is make sure that you find the sacral base, which you know you're going to
00:27:2200:27:29
come off the flat sacrum, and then just fall off the top of it so that you
00:27:2900:27:35
find L5-S1. Now those are the two joints most likely to become hypermobile,
00:27:3500:27:41
but in a lot of individuals with a chronic history of lumbar pathology they
00:27:4100:27:47
can also get stiff. So knowing how to palpate and then mobilize L4-L5, and L5
00:27:4700:27:52
and S1 are important techniques to have in your arsenal. Of
00:27:5200:27:59
course the technique that we use is the same as all of the other vertebral
00:27:5900:28:04
UPA's that we've done. Once you find that facet, find the first resistance barrier
00:28:0400:28:09
and then find the end of arthrokinematic range, and you're going to have to press
00:28:0900:28:12
down pretty good in the lumbar spine. This is one of those techniques that
00:28:1200:28:17
having a good mentor will definitely give you the confidence to push this to
00:28:1700:28:22
end range, and you'll back off to 50% between, and then you can do your grade
00:28:2200:28:26
fours right there at 50%, or you can back off to zero resistance and go to 50%
00:28:2600:28:33
like a grade three. And of course make sure you follow through your protocols
00:28:3300:28:40
getting a increase in joint mobility before you stop, probably 30 seconds or
00:28:4000:28:44
more. So there you have it assess, address, reassess. Make sure that
00:28:4400:28:49
every time you choose a joint based manual therapy technique it is based on
00:28:4900:28:52
an assessment, and that you return to that assessment after you've finished
00:28:5200:28:57
the intervention to see if it was effective for the individual, the
00:28:5700:29:01
patient or client that you have in front of you. Ensure that you continue to learn
00:29:0100:29:06
your Anatomy because your Anatomy is going to help you with your hand
00:29:0600:29:11
placement, with understanding what a joint can do, with understanding what you
00:29:1100:29:17
may gain from this particular technique; and of course practice, you have to
00:29:1700:29:22
practice these techniques hopefully not for the first time on a patient or
00:29:2200:29:27
client who just walked in the door. If you can find a more senior instructor or
00:29:2700:29:32
a mentor to give you some really good hands-on instruction, use your peers for
00:29:3200:29:40
some good feedback, and of course always look for live education to help with
00:29:4000:29:44
your manual therapy techniques. I know these videos make education very
00:29:4400:29:50
convenient but there is no substitute for learning manual therapy in a live
