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.

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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.

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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 proce...
The Derangements and Their Treatment DERANGEMENT ONE Central or symmetrical pain across L4/5. Rarely buttock or thigh pain No deformity In Derangement One the disturbance within the disc is at a comparatively embryonic stage. Due to minor posterior migration of the nucleus and its invasion of a small radial fissure in the inner annulus, there is a minimal disturbance of disc material. This causes mechanical deformation of structures posteriorly within and about the disc, resulting in central or symmetrical low back pain. The accumulation of disc material also leads to a minor blockage in the affected joint preventing full extension, but the blockage is not enough to force the deformity of kyphosis upon the joint. In patients with Derangement One the history, symptoms and signs are usually typical of the syndrome, and the test movements confirm the diagnosis of derangement. Because the disturbance within the joint is relatively small it responds well to the patients’ own movements, and the majority of pati...
TYPICAL TREATMENT PROGRESSION — THE DYSFUNCTION SYNDROME Day one Assessment and conclusion/diagnosis. Explanation of the cause of dysfunction and the treatment approach. Postural correction and instructions, especially regarding sitting; demonstrate the use of a lumbar support. Commence with exercises to recover function — that is, extension in lying, flexion in lying, or side gliding in standing, whatever procedure is indicated. Emphasise the need to experience some discomfort during the exercises, and the importance of frequent exercising during the day. If flexion in lying is recommended, we must warn to stop exercising if the symptoms quickly worsen. We may have overlooked derangement, or commenced the procedure too early following recent derangement. Always follow flexion exercises with some extension. Day two Confirm diagnosis. Check postural correction. Completely repeat'postural correction and instructions. Check exercises. If improving nothing should be changed. If not improving, ensure tha...
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 ...
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 n...