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.

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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.

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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.

Back Pain. Diagnosis THE THERAPIST’S RESPONSIBILITY The therapist is part of the team involved in the treatment and rehabilitation of patients suffering low back pain. In some countries manipulative therapists are primary contact practitioners. Consequently, their diagnostic skills have greatly improved, enabling them to define which mechanical conditions can be helped by mechanical therapy and to separate these conditions from the nonmechanical lesions which have no place in the therapy clinic. However, differential diagnosis is really not within the scope of manipulative therapy. It is my view that differential diagnosing by medical practitioners is necessary to exclude serious and unsuitable pathologies from being referred for mechanical therapy. In making diagnoses the manipulative therapist should confine himself to musculo-skeletal mechanical lesions. Specialised in this field, he is usually able to make far more accurate diagnoses than most medical practitioners. As the manipulative therapy prof...
Spine Health. PROCEDURE 2 — LYING PRONE IN EXTENSION The patient, already lying prone, places the elbows under the shoulders and raises the top half of his body so that he comes to lean on elbows and forearms while pelvis and thighs remain on the couch. In this position the lumbar lordosis is automatically increased. Emphasis must be placed on allowing the low back to sag and the lordosis to increase. Fig. Lying prone in extension. Effects: Procedure 2 is a progression of procedure 1 and merely enhances its effects by increasing extension. Again, in derangement some time must be allowed to affect the contents of the disc and, if possible patients should remain in this position for five to ten minutes. In more acute patients sustained extension may not be well tolerated due to pain, and initially we must rely on the use of intermittent extension.
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-...
The Derangement Syndrome Of all mechanical low back problems that are encountered in general medical practise, mechanical derangement of the intervertebral disc is potentially the most disabling. It is my belief that in the lumbar spine, if in no other area, disturbance of the intervertebral disc mechanism is responsible for the production of symptoms in as many as ninety-five percent of our patients. Twenty-five years of clinical observation and treatment of lumbar conditions have convinced me that certain phenomena and the various movements which affect them, can occur only because of the hydrostatic properties invested in the intervertebral disc. For thirty years Cyriax has attributed lumbar pain to internal derangement of the intervertebral disc mechanism. He has outlined the cause of lumbago, and proposed that pain of a slow onset is likely to be produced by a nuclear protrusion while that of a sudden onset is caused by a displaced annular fragment. Although at present we are unable to prove either of ...
Back pain. The Cause of Pain THE NOCICEPTIVE RECEPTOR SYSTEM Most tissues in the body possess a system of nerve endings which, being particularly sensitive to tissue dysfunction, may be referred to as nociceptive receptors. The free nerve endings of the nociceptive system provide the means by which we are made aware of pain. Wyke describes the distribution of the nociceptive receptor system in the lumbar area: it is found in the skin and subcutaneous tissue; throughout the fibrous capsule of all the synovial apophyseal joints and sacro-iliac joints; in the longitudinal ligaments, the fiaval and interspinous ligaments and sacro-iliac ligaments; in the periosteum covering the vertebral bodies and arches, and in the fascia, aponeuroses and tendons attached thereto; and also in the spinal dura mater, including the dural sleeves surrounding the nerve roots. The nociceptive innervation of the spinal ligaments varies from one ligament to another. The system is found to be most dense in the posterior longitudinal l...