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.

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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.

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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.

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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 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-...
Spine Health. PROCEDURE 13 — FLEXION IN LYING The patient lies supine with the knees and hips flexed to about forty-five degrees and the feet flat on the couch. He bends the knees up towards the chest, firmly clasps the hands about them and applies overpressure to achieve maximum stress. The knees are then released and the feet placed back on the couch. The sequence is repeated about ten times. The first two or three flexion stresses are applied cautiously, but when the procedure is found to be safe the remaining pressures may become successively stronger, the last two or three being applied to the maximum possible. Fig. Flexion in lying. Effects: Flexion in lying causes a stretching of the posterior wall of the annulus, the posterior longitudinal ligament, the capsules of the facet joints, and other soft tissues. As the movement takes place from below upwards the lower lumbar and lumbo-sacral joints are placed on full stretch at the beginning of the exercise as soon as movement is initiated. Thus, the procedure is very i...
Spine Health. PROCEDURE 16 — CORRECTION OF LATERAL SHIFT This procedure has two parts: first the deformity in scoliosis is corrected; then, if present, the deformity in kyphosis is reduced and full extension is restored. The patient, standing with the feet about thirty centimeters apart, is asked to clearly define the areas where pain is being felt at present. The therapist stands on the side to which the patient is deviating and places the patient’s near elbow at a right angle by his side. The elbow will be used to increase the lateral pressure against the patient’s rib cage. The therapist’s arms encircle the patient’s trunk, clasping the hands about the rim of the pelvis. Now the therapist presses his shoulder against the patient’s elbow, pushing the patient’s rib cage, thoracic and upper lumbar spine away while at the same time drawing the patient’s pelvis towards himself. In this manner the deformity in scoliosis is reduced and, if possible slightly overcorrected. Initially, there will be significant resistance to the procedure, wh...
Hyperlordosis: Treatment, Prevention, and More What’s hyperlordosis? Human spines are naturally curved, but too much curve can cause problems. Hyperlordosis is when the inward curve of the spine in your lower back is exaggerated. This condition is also called swayback or saddleback. Hyperlordosis can occur in all ages, but it’s rare in children. It’s a reversible condition. Keep reading to learn about the symptoms and causes of hyperlordosis and how it’s treated. What are the symptoms of hyperlordosis? If you have hyperlordosis, the exaggerated curve of your spine will cause your stomach to thrust forward and your bottom to push out. From the side, the inward curve of your spine will look arched, like the letter C. You can see the arched C if you look at your profile in a full-length mirror. You may have lower back pain or neck pain, or restricted movement. There’s limited evidence connecting hyperlordosis to lower back pain, however. Most hyperlordosis is mild, and your back remains flexible. If the arch in your bac...
TREATMENT OF THE DERANGEMENT SYNDROME Of all patients with low back pain those having derangement of the intervertebral disc are the most interesting and rewarding to treat. As in dysfunction, it is essential in derangement that from the very first treatment correction of the sitting posture be achieved, but in the early and acute stages of derangement emphasis is placed on the maintenance of lordosis rather than the obtaining of the correct posture. Failure in this respect means failure of what otherwise might be a successful reduction of the derangement. So often it occurs that a patient describes a significant relief from pain and is visibly improved immediately following treatment, but later that same day after sitting for some time he is unable to straighten up on rising from sitting and the symptoms have returned just as they were before treatment. Usually the patient clearly understands the dangers of bending and stooping and carefully avoids these movements. But the hidden dangers of sustained flexion incurred in t...