Introduction to Lumbar spine mobilisation

1. LUMBAR SPINE MOBILISATION

2. DEFINITION
• Joint mobilisation is the skilled passive
movement of the articular surfaces performed
by a physical therapist to decrease pain or
increase joint mobility.
Edward P. Mulligan, 2001
• Spinal mobilisation is described in terms of
improving mobility in areas of the spine that
are restricted

3. Define the terms used in Joint
Mobilization
•passive, skilled manual therapy techniques
•applied at joint and related soft tissues
• varying speed and amplitude
•using physiological or accessory motion
Mobilization
•self stretching technique that specifically use joint traction/glides
that direct the stretch force to the joint capsule.
Self-mobilization
•concurrent application of sustained accessory mobilization
applied by a therapist and an active physiological movement to
ER applied by the patient.
Mobilization with
movement
(MWM)
•movement that patient can do voluntarily
Physiological
movement
•movement in the joint & surrounding soft tissues that are
necessary for normal ROM, BUT not actively performed by
patient.
Accessory
movement

4. Joint kinematics
Understanding joint movement…
• Physiological – “movement you see”
• Accessory – “movement you feel”

5. Physiological
• Known as Osteokinematic joint movements
• The natural movements that occur in our
joints
• Rotational around an axis
• Can be analysed from movement quality and
symptom response

6. Accessory
• Known as Arthrokinematic joint movements
• Articular movements between two joint
surfaces: (Roll /Glide /Spin)
• Occur with all active/passive physiological
joint movement
• Necessary for full, pain-free range of
movement
• Movements that we FEEL

7. THE DIFFERENCE

8. CONCAVE CONVEX RULE

9. Fryette’s Laws
1. First Law / Neutral Mechanics
– Side-bending to the spine in one direction will
result in rotation to the opposite side. (IN
NEUTRAL SPINE)
2. Second Law / Non – Neutral Mechanics
– Side-bending to the spine in one direction will
result in rotation to the same side. (IN
FLEXION/ EXTENSION)
3. Third Law – Increasing range of motion in one
plane of motion will result in a decrease in
motion in the other 2 planes.

10. NEUTRAL MECHANICS NON-NEUTRAL MECHANICS

11. Grades of Oscillations
(Maitland)
Dosages:
 Grade I - small amplitude rhythmic oscillations at the
beginning of the range (pain and spasm)
 Grade II - large amplitude rhythmic oscillations within the
midrange of the movement, not reaching the limit (pain
and spasm)
 Grade III - large amplitude rhythmic oscillations up to the
limit of available motion and stressed into tissue resistance
(into restriction)
 Grade IV - small amplitude rhythmic oscillations to the limit
of available motion and stress into the tissue resistance
(not pain)
 Grade V - small amplitude, high velocity(quick) thrust
manipulation at end range- required advanced training!

13. Sustained Translatory Joint-Play Techniques
Dosages:
 Grade I (loosen)- small amplitude distraction is
applied where no stress is placed on the capsule.
 Grade II (tighten) – enough distraction or glide is
applied to tighten the tissues around the joint.
 Grade III (stretch) – a distraction or glide is applied
with an amplitude large enough to place stretch on
the joint capsule and surrounding periarticular
structures.

16. Treatment Principles
1. The Desired Effect - what effect of the
mobilisation is the therapist wanting? Relieve
pain or stretch tissues?
2. The Starting Position - of patient and
therapist to make the treatment effective
and comfortable.
3. The Direction - AP/PA; Cephalad/Caudad

17. 4. The Method of Application - The position,
grade, amplitude, rhythm and duration of the
technique.
5. The Expected Response - Should the patient
be pain-free, have an increased range or have
reduced soreness?
(Hengeveld and Banks, 2005)
Treatment Principles 1 oscillation per second =
30 oscillations for more pain / 60 for
hypomobility (Donatelli, 2001)

18. INDICATIONS
• Pain
• Stiffness
• Hypomobility due to joint dysfunctions with
altered joint mechanics
• Pain associated with stiffness

19. Contraindications/Precautions to
Vertebral Mobilisations
• Neurological:
– Patient with arm pain and neurological signs, from
two nerve routes
Disturbance of bladder and bowel function, or
perineal anaesthesia
Spinal cord symptoms
• Hypermobility:
– If a vertebra in the spine was hypermobile
compared to the other vertebra, care must be
taken to avoid putting excessive strain on the
hypermobile joint

20. • Radiological changes:
– Patients with rheumatoid arthritis and osteoporosis
are contraindications to forceful mobilizations.
Any pathology leading to significant bone-weakening
such as tumours, infections, long-term corticosteroid
medication, fracture
• Vascular
– Aortic aneurysm, bleeding into joints, e.g. severe
Haemophilia
• Pregnancy
• Musculoskeletal deformity
– Spondylolysis, spondylolisthesis

21. Effects of Joint Mobilization
• Neurophysiological effects –
– Stimulates mechanoreceptors to  pain
– Affect muscle spasm & muscle guarding – nociceptive stimulation
– Increase in awareness of position & motion because of afferent nerve
impulses
• Nutritional effects –
– Distraction or small gliding movements – cause synovial fluid movement
– Movement can improve nutrient exchange due to joint swelling &
immobilization
• Mechanical effects –
– Improve mobility of hypomobile joints (adhesions & thickened CT from
immobilization – loosens)
– Maintains extensibility & tensile strength of articular tissues
• Cracking noise may sometimes occur

22. LUMBAR VERTEBRAE

25. To Improve Flexion

26. To improve Extension

27. To improve Lateral Flexion

28. To improve Rotation

29. Mobilisations of the Lumbar Spine
• Passive Accesory Intervertebral Movements
(PAIVMs) – Predominantly For Evaluation
• Passive Physiological Intervertebral
Movements (PPIVMs) – For
Evaluation/Management

30. MAITLAND TECHNIQUES
• Central Posteroanterior (PA) Mobilisation
Technique
• Unilateral PA Mobilisation Technique
• Lateral/Transverse Mobilisation Technique
• Longitudinal Mobilisation Technique
• Antero Posterior Mobilisation Technique

31. PA GLIDE (CENTRAL)

32. PA GLIDE (UNILATERAL)

33. LATERAL GLIDE

34. LONGITUDINAL GLIDE

35. ANTERIOR CENTRAL VERTEBRAL
PRESSURE

36. MULLIGAN TECHNIQUES
• Natural Apophyseal Glides (NAGS)
• Reverse NAGS
• Sustained Natural Apophyseal Glides (SNAGS)
• Mobilisations with Movement (MWMs)
• Spinal mobilisations with LEG movements
(SMWLMS)

37. Sustained Natural Apophyseal
Glides (SNAGS)

38. THE MULLIGAN BELT

39. MOBILISATION WITH MOVEMENT (MWM)

40. SPINAL MOBILISATION WITH LEG
MOVEMENT (SMWLM)

42. THANK YOU