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Spine Health. PROCEDURE 12 — ROTATION MANIPULATION IN FLEXION

The sequence of procedure 11 must be followed completely to perform the required pre-manipulative testing. If the manipulation is indicated a sudden thrust of high velocity and small amplitude is performed, moving the spine into extreme side bending and rotation.

Fig. Rotation manipulation in flexion.

Effects:

There are many techniques devised for rotation manipulation of the lumbar spine. When rotation of the lumbar spine is achieved by using the legs of the patient as a lever or fulcrum of movement, confusion arises as to the direction in which the lumbar spine rotates. This is judged by the movement of the upper vertebrae in relation to the lower — for example, if the patient is lying supine and the legs are taken to the right, then the lumbar spine rotates to the left.

It has become widely accepted that rotation manipulation of the spine should be performed by rotation away from the painful side. This has applied to derangement as well as dysfunction, because hitherto no differentiation has been made between these syndromes. I wish to emphasise that, while this practise is correct for the majority of derangements, it is useless at best when applied to dysfunction. Because there are more low back pain patients with dysfunction than with derangement, it is essential to determine precisely which syndrome is present.

Premanipulative testing with the lumbar spine held in full rotation stretch prior to the administration of the manipulative thrust will indicate if we have chosen the correct direction in which the manipulation should be performed. In derangement this will always be in the direction that causes a decrease, centralisation or abolition of unilateral pain. Reduction of symptoms may be achieved with the lumbar spine rotated either towards or away from the painful side. The deciding factor for the direction of the manipulation must be the reduction of mechanical deformation, irrespective of the fact whether this is achieved with movement towards or away from the painful side. In dysfunction the patient should experience an enhancement of pain, but the pain must never peripheralise. The patient with dysfunction may have to be manipulated in both directions, which is rarely the case in derangement.

A rotation manipulation is often described as having a gapping effect on the facet joints. Although this idea is widely held, it is almost impossible to detect on x-rays, taken during manipulation, that movement occurs at the facet joints. However, significant movement can be-observed between the vertebral bodies. It is my contention that a rotation manipulation influences the nucleus and annulus of the disc more than the facet joints. Due to the torsion and side bending provided with the procedure, the annular wall must become tightened and under increased tension. This could possibly influence a distorted nucleus, at least as long as the annular wall is intact.

Manipulation consistently applied with the painful side uppermost in the belief that gapping of the facets is required to relieve the patient’s symptoms, is no longer tenable. We must be guided by the increase and decrease of mechanical deformation instead of conjecture.

The term ‘rotation manipulation’ is perhaps incorrect, as there is a much greater side bending than rotation component when spinal rotation is performed.

Lightly built therapists who feel that they have inadequate weight to perform the rotation thrust procedure in flexion, can achieve equally satisfactory results by using the sustained rotation procedure.

Spine Health. PROCEDURE 11 — SUSTAINED ROTATION/MOBILISATION IN FLEXION

The patient lies supine on the couch, and the therapist stands on the side to which the legs are to be drawn, facing the head end of the couch. The patient’s far shoulder is held firmly on the couch by the therapist’s near hand, providing fixation and stabilisation. With the other hand the therapist flexes the patient’s hips and knees to a rightangle and carries them towards himself, causing the lumbar spine to rotate. With the patient’s ankles resting on the therapist’s thigh the knees are allowed to sink as far as possible and the legs are permitted to rest in that extreme position. The lumbar spine is now hanging on its ligaments in a position which combines side bending and rotation. By pushing the knees further towards the floor the therapist applies overpressure to take up the remaining slack in the lumbar spine. Depending on the purpose for which the procedure is used, the position of extreme rotation is maintained for a shorter or longer period.

Fig. Sustained rotation/mobilisation in flexion.

Effects:

The procedure is mainly used in derangement. Sustained rotation for about thirty to forty seconds provides the time factor required to allow alteration of the position of the fluid nucleus within the disc. In those situations where time is important in the reduction this procedure may effect relief that will not be obtained by the much quicker performed rotation thrust (procedure 12). During the period that rotation is sustained the patient should be watched closely and asked constantly about the behaviour of pain. Any sign of peripheralisation of symptoms indicates that more than enough time has been spent in this position.

The procedure may also be used as a mobilising technique in dysfunction, or as premanipulative testing in dysfunction as well as in derangement. In these cases the rotation is less sustained or performed in a rhythmical mobilising manner.

If a small therapist cannot reach across the patient to stabilise his shoulder, a seat belt fastened firmly across the patient’s upper chest provides adequate fixation. Alternatively, a second person may be used to hold the patient down.

Spine Health. PROCEDURE 10 — ROTATION MANIPULATION IN EXTENSION

The patient lies prone as for procedure 1. The therapist stands to one side of the patient and, having selected the correct segment, places the hands on either side of the spine as for the technique of rotation mobilisation in extension (procedure 9), which is always applied as a premanipulative testing procedure.

The information obtained from the mobilisation is vital and determines on which side and in which direction the manipulation is to be performed. If following testing the manipulation is indicated, the therapist reinforces the one hand with the other on the appropriate transverse process. The manipulation is then performed as in procedure 8.

Fig. Rotation manipulation in extension.

Effects:

The effects of the external force and the reasons for its use are the same as for procedure 9. When the desired result is not obtained with the mobilising technique, manipulation is indicated under certain circumstances. Regarding the direction in which the manipulation is to be performed the same rules apply as for procedure 9.

Spine Health. PROCEDURE 9 — ROTATION MOBILISATION IN EXTENSION

The position of patient and therapist is the same as for procedure 7. By modifying the technique of extension mobilisation so that the pressure is applied first to the transverse process on the one side and then on the other side of the appropriate segment a rocking effect is obtained. Each time the vertebra is rotated away from the side to which the pressure is applied — for example, pressure on the right transverse process of the fourth lumbar vertebra causes left rotation of the same vertebra. The technique should be repeated about ten times on the involved segment and, if indicated, adjacent segments should be treated as well.

Fig. Rotation mobilisation in extension.

Effects:

Also here the external force applied by the therapist enhances the effects on derangement and dysfunction as described for the previous extension procedures. The reasons for adding therapist-technique are the same as for procedure 7.

In general, unilateral techniques are likely to effect unilateral or asymmetrical symptoms sooner and more efficiently than bilateral or central techniques. But once centralisation of symptoms has taken place, treatment may be continued with central or bilateral techniques. Thus, in derangement rotation mobilisation in extension may have to be performed first to bring about centralisation of nuclear material in the disc. This is followed by symmetrical extension mobilisation to restore the nucleus to its more anterior position.

Occasionally a click is felt during mobilisation. A click often indicates a reduction of derangement, and we should immediately assess if this is the case. If the patient has improved significantly as a result of this technique, any further treatment may disturb the reduction and the treatment session should be terminated at this point.

During the procedure the patient may describe an enhancement of the pain by pressure on one side with a corresponding reduction of the pain by pressure on the other side. This is valuable information on which further treatment will be based. We must keep in mind that we are affecting the pain by increasing or decreasing mechanical deformation. In dysfunction an increase in mechanical deformation with certain limits is desirable and pain should be produced or increased with the application of the technique. In derangement an increase in mechanical deformation is extremely undesirable, and we should aim for a decrease instead with centralisation, reduction or abolition of the pain. Therefore, precise identification of the syndrome to be treated is essential to determine whether rotation mobilisation should be performed towards the painful or the painfree side.

Spine Health. PROCEDURE 8 — EXTENSION MANIPULATION

There are many techniques devised for manipulation of the lumbar spine in extension. It is not important which technique is used, provided the technique is performed on the properly selected patient and applied in the correct direction. The technique that I recommend is similar to the first two manipulations described by Cyriax for the reduction of a lumbar disc lesion.

The patient lies prone as for procedure 1. The therapist stands to one side of the patient and, having selected the affected segment, places the hands on either side of the spine as for the technique of extension mobilisation (procedure 7), which is always applied as a premanipulative testing procedure. If following testing the manipulation is indicated, the therapist leans over the patient with the arms at right angles to the spine and forces slowly downwards until the spine feels taut. Then a high velocity thrust of very short amplitude is applied and immediately released.

Fig. Extension manipulation.

The effects of the external force and the reasons for its use are the same as for procedure 7. When the desired result is not obtained with the mobilising techniques, manipulation is indicated under certain circumstances.

The extension thrust is used by many manipulators, and there is difference of opinion regarding the structures that may be influenced by this technique. Cyriax states that it reduces derangement of an annular fragment of the disc. Others propose reduction of facet locking, tearing of adhesions and reduction of nerve root entrapment. Whatever the true mechanism may be, properly selected patients often experience a click or a dull thud. In most instances the click is followed by a change, usually an improvement, in the patient’s signs and symptoms.

Spine Health. PROCEDURE 7 — EXTENSION MOBILISATION

The patient lies prone as for procedure 1. The therapist stands to one side of the patient, crosses the arms and places the heels of the hands on the transverse processes of the appropriate lumbar segment. A gentle pressure is applied symmetrically and immediately released, but the hands must not lose contact. This is repeated rhythmically to the same segment about ten times. Each pressure is a little stronger than the previous one, depending on the patient’s tolerance and the behaviour of the pain. The procedure should be applied to the adjacent segments, one at a time, until all the areas affected have been mobilised.

Fig. Positioning of hands prior to extension mobilisation. Extension mobilisation.

Effects:

In this procedure the external force applied by the therapist enhances the effects on derangement and dysfunction as described for the previous extension procedures.

In general, symmetrical pressures are used on patients with central and bilateral symptoms. Therapist-technique must be added when the patient is unable to reduce derangement or resolve dysfunction by the self-treatment procedures. That situation appears in derangement when instead of progressively lessening pain extension in lying (procedure 3) causes the same pain with each repetition. Under those circumstances extension mobilisation is indicated.

Spine Health. PROCEDURE 6 — EXTENSION IN STANDING

The patient stands with the feet well apart and places the hands (fingers pointing backwards) in the small of the back across the belt line. He leans backwards as far as possible, using the hands as a fulcrum, and then returns to neutral standing. The exercise is repeated about ten times. As with extension in lying it is necessary to move to the very maximum to obtain the desired result.

Fig. Extension in standing.

Effects:

Extension in standing produces similar effects on derangement and dysfunction as extension in lying, but it is less effective in the earlier treatment stages of both syndromes. Whenever extension in lying is prevented by circumstances, an extension stress can be given by extension in standing.

In derangement, extension in standing is designed to reduce accumulation of nuclear material in the posterior compartment of the intervertebral joint, provided this accumulation is not gross. In the latter case extension in lying will have to be performed first. The procedure is very important in the prevention of the onset of tow back pain during or after prolonged sitting or activities involving prolonged stooping, and is very effective when performed before pain is actually felt.

Spine Health. PROCEDURE 5 — SUSTAINED EXTENSION

To apply a sustained extension stress to the lumbar spine an adjustable couch, one end of which may be raised, is a necessary piece of equipment. The patient lies prone with his head at the adjustable end of the couch which is gradually raised, about one to two inches at the time over a five to ten minute period. Once the maximum possible degree of extension is reached, the position may be held for two to ten minutes, according to the patient’s tolerance. When lowering the patient the adjustable end of the couch should slowly be returned to the horizontal over a period of two to three minutes. This must not be done rapidly, for acute low back pain may result.

Fig. Sustained extension.

Effects:

The procedure is predominantly used in the treatment of derangement. The effect is similar to that of the third procedure, but a time factor is added with the graduated increase and the sustained nature of the extension. In certain circumstances a sustained extension stress is preferable to a repeated extension stress.

The centralisation phenomenon must be watched closely. Any suggestion that the pain is moving or increasing peripherally must lead to the immediate but slow lowering of the couch. It is interesting to note that an increase in central low back pain as the couch is lowered nearly always indicates a good response to the treatment, whereas when there is no increase in central pain patients tend to have little or no improvement following this procedure.

Spine Health. PROCEDURE 4 — EXTENSION IN LYING WITH BELT FIXATION

The patient’s position and the exercise are the same as in the third procedure, but now a fixating belt is placed at or just below the segments to be extended. The safety belt is the first simple external aid, used to enhance maximum extension. It does so by preventing the pelvis and lumbar spine lifting from the couch. Other methods of restraint may be used effectively, for example the body weight of a young son or daughter when exercising at home.

Fig. Extension in lying with belt fixation.

Effects:

This procedure creates a greater and more localised passive extension stress than the previous ones. It is particularly suitable for stretching in the case of extension dysfunction, and is more often required in dysfunction than in derangement.

In dysfunction some pain will be experienced in the small of the back while exercising, because contracted tissues are being stretched. In derangement the rules pertaining to the centralisation phenomenon must be observed, and the procedure stopped if peripheral pain is produced or increased.

Spine Health. PROCEDURE 3 — EXTENSION IN LYING

The patient, already lying prone, places the hands (palms down) near the shoulders as for the traditional press-up exercise. He now presses the top half of his body up by straightening the arms, while the bottom half, from the pelvis down is allowed to sag with gravity. The top half of the body is then lowered and the exercise is repeated about ten times. The first two or three movements should be carried out with some caution, but once these are found to be safe the remaining extension stresses may become successively stronger until the last movement is made to the maximum possible extension range. If the first series of exercises appears beneficial, then a second series may be indicated. More vigour can be applied and a better effect will be obtained if the last two or three extension stresses are sustained for a few seconds.

It is essential to obtain the maximum elevation by the tenth excursion and once obtained the lumbar spine should be permitted to relax into the most extreme ‘sagged’ position.

Fig. Extension in lying.

Effects:

This procedure is a further progression of the previous two. Instead of a sustained extension stress on the contents and surrounding structures of the lumbar segments, there is now an intermittent extension stress, having a pumping as well as a stretching effect.

This procedure is the most important and effective in the treatment of derangement as well as extension dysfunction. The very maximum degree of extension possible without external assistance, is obtained with this exercise. An increase of central low back pain at maximum elevation can be expected and should not cause any concern as it will gradually wear off. It is usually described as a strain pain and differs from the pain which has caused initial consultation. In addition to the effects on the disc and periarticular structures there are two other physiologically related phenomena that could possibly result from the performance of this exercise.

The self sealing phenomenon

Evidence gathered by Markolf and Morris suggests that a self sealing mechanism exists within the disc and appears shortly after injury. The initial injury weakens the annulus but appropriate stress applied subsequently results in restoration of near normal strength, suggesting that the disc has a remarkable recovery ability and that certain stresses may enhance rapid recovery. White and Panjabi conclude that the self sealing phenomena is mechanical in nature and is not dependent on the viscosity or softness of the disc, for the study was performed on degenerative as well as normal discs.

My question arising from this information is … Does the performance of repeated passive extension in lying cause a reversal of the posterior migration of the nucleus into the developing radial fissure? Does the movement then initiate the self sealing phenomena?

Cartilaginous repair

Following trauma articular surfaces are normally rested or immobilised to permit healing. It is well known that scar tissue is laid down under these circumstances and damaged articular cartilage is replaced with fibrous collagen. Recent investigations by Salter suggest that if passive continuous motion is applied to joints containing traumatised intra articular cartilage, the damaged cartilage is replaced by true cartilaginous cells instead of scar tissue, and further, these joints do not develop arthritic changes subsequently. The evidence has yet to be confirmed in human studies. We can now pose the question … Does the regular performance of passive extension following lumbar disc damage enhance the quality or improve the nature of the healing tissues of the posterior annulus?