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.
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.