manual mobilization of the lumbar and thoracic spine · kaltenborn f, evjenth o, kaltenborn t,...

Manual Mobilization of the Lumbar

and Thoracic Spine

Brian Vesci, MA, ATC

Hollie Walusz, MA, ATC

Stacey Hardin, PT, DPT, ATC

Stephanie Naylor, EdM, ATC

Boston University Slideshow Title Goes Here

Objectives

Understand the osteo- and arthrokinematics of the

spine within the context of the clinical application of

joint mobilization.

Identify physiologic implications leading to the

classification and treatment of patients shown to

benefit from high velocity low amplitude mobilizations.

Instruct how to, and evaluate attendees’ ability to,

perform high velocity low amplitude thrust

mobilizations for the lumbar and thoracic spine,

allowing them to develop a plan to integrate these

techniques into their clinical practice.


Joint Mobilizations: Overview

Patient explanation



Patient explanation

Identify anatomy of joint



Patient explanation

Identify anatomy of joint Identify stable component



Patient explanation


Identify mobilization

component

Boston University Slideshow Title Goes Here Roll

Glide



Patient explanation



component

Patient positioning



Patient explanation



component

Patient positioning

Clinician positioning

(hand placement)


FIN

ISH



Patient explanation



component

Patient positioning


(hand placement)

Direction of force

(restriction)



Patient explanation



component

Patient positioning


(hand placement)

Direction of force

(restriction) Treatment plane


Concave on Convex1

Treatment Plane


Convex on Concave1

Treatment Plane


Convex/Concave Rule:

Remix Edition

Brandt et al.2

Evidence based review revealing translational motion in GH joint did

not always follow convex/concave rule

My solution: Trust your physical exam



Patient explanation



component

Patient positioning


(hand placement)

Direction of force

(restriction) Treatment plane

Grade of mobilization3


Contraindications

Hypermobility

Suspected factures

Instability

Immediate Post- Op

Infections

Disk Herniations

Open Wounds

Malignancy

Acute Inflammation

Veterbral Basilar

Insufficiency

Idiopathic pain Clinician inexperience


Defining Grades of Motion

Mobilization as a continuum – Maitland3

Velocity

Amplitude

Position in available motion


Grades3

Normal

Joint

Normal Tissue

Resistance to

Movement


Grades3

Normal

Joint

I

Normal Tissue

Resistance to

Movement


Grades3

Normal

Joint

I

II

Normal Tissue

Resistance to

Movement


Grades3

Normal

Joint

I

II

III

Normal Tissue

Resistance to

Movement


Grades3

Normal

Joint

I

II

III

IV

Normal Tissue

Resistance to

Movement


Grades3

Pathologic

Joint

I

II

Normal Tissue

Resistance to

Movement

III


Grades3

Pathologic

Joint

I

II

Normal Tissue

Resistance to

Movement

Pathologic

Restriction

III


Grades3

Pathologic

Joint

I

II

IV

Normal Tissue

Resistance to

Movement

Pathologic

Restriction

III


Grades3

Pathologic

Joint

I

II

IV

Normal Tissue

Resistance to

Movement

V

Pathologic

Restriction

III


Normal

Joint

I II

III

IV

Normal Tissue

Resistance to

Movement

Pathologic

Joint

I

II

IV

Pathologic

Restriction

III

V


Normal

Joint

I II

III

IV

Normal Tissue

Resistance to

Movement

Pathologic

Joint

I

II

Pathologic

Restriction

III

IV

V


Lumbar – Arthrology4

Intralumbar apophyseal joints


Lumbar – Arthrokinematics5

Intralumbar

apophyseal joints

(L1-L5)

flexion-extension

rotation

lateral flexion



Flexion



Extension



Axial rotation



Lateral flexion


Lumbar – Clinical Application

Imaging?

Clinical prediction rule for mobilization6,7 Duration < 16 days

No symptoms distal to knee

FABQ work subscale < 19

≥ 1 hypomobile lumbar spinal segment

≥ 1 hip with > 35°of internal rotation range of motion

Patient positioning


Lumbar – Clinical Application4

Glides:

Central posterior – anterior

Unilateral posterior – anterior

Anterior – posterior is not really an option. Solution?


Thoracic – Arthrology4

Intrathoracic apophyseal joints

Costovetebral joints


Thoracic – Arthrokinematics5

Intrathoracic

apophyseal joints

(T1-T12)

flexion-extension

rotation

lateral flexion



Flexion



Extension



Axial rotation



Lateral flexion


Thoracic – Clinical Application4

Soft tissue vs facet joint dysfunction

Rib mobilization

Proper breathing technique


Thoracic – Clinical Application4

Glides:

Central posterior – anterior (PA glide)

Unilateral posterior – anterior (PA glide)

Anterior – posterior (AP glide) is not really an option.

Solution?


References

1. Kaltenborn F, Evjenth O, Kaltenborn T, Morgan D, Vollowitz E. Manual Mobilization

of the Joints: Joint Examination and Basic Treatment. Vol 1. 4th ed. Oslo: Norli; 2007.

2. Brandt C, Sole G, Krause MW, Nel M. An evidence-based review on the validity of

the Kaltenborn rule as applied to the glenohumeral joint. Manual therapy.

2007;12(1):3-11.

3. Hengeveld E, Banks K, eds. Maitland's Vertebral Manipulation: Management of

Neuromusclar Disorders. Oberentfelden: Elsevier; 2014; No. 1.

4. Neumann D. Kinesiology of the Musculoskeletal System: Foundations for Physical

Rehabilitation. University of Michigan: Mosby; 2002.


References

5. Group MM. Medical Illustration. 2006;

http://www.medicalmultimediagroup.com/content/medical-illustration. Accessed

December 14, 2015.

6. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients

with low back pain who demonstrate short-term improvement with spinal

manipulation. Spine. 2002;27(24):2835-2843.

7. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients

with low back pain most likely to benefit from spinal manipulation: a validation study.

Annals of internal medicine. 2004;141(12):920-928.

http://www.medicalmultimediagroup.com/content/medical-illustration



manual mobilization of the lumbar and thoracic spine · kaltenborn f, evjenth o, kaltenborn t,...

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