Manual Therapy of

the Lumbar Spine

By:
Mohammed Helmy, P.T.
Manual Therapy of the Lumbar Spine

Anatomy of the Lumbar Spine

We will talk about:

1- Osteology
2- Ligamentous structure
3- Musculature

1- Osteology:

Spinous Process is broad Linear structure (so it is a good place

to mobilize from) and it is at the same level of transverse
processes and body.

The transverse processes are long and slender. They are

horizontal in the upper three lumbar vertebrae and incline a
little upward in the lower two. They are situated in front of the
articular processes instead of behind them as in the thoracic
vertebrae. They are mostly not palpable except for L3 in thinny
population.

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The laminae are broad, short, and strong. They form the
posterior portion of the vertebral arch. They are forming the
posterior part of the spinal canal padded with ligamentum
flavum .
It is one of the superficial structures of the vertebra so
laminectomy is one of the common surgeries specially in cases
with spinal canal stenosis.

The pedicles are very strong, directed backward from the upper
part of the vertebral body. The pedicle is sometimes used as a
portal of entrance into the vertebral body for fixation with
pedicle screws or for placement of bone cement as with
kyphoplasty or vertebroplasty.

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The superior and inferior articular processes are well-defined,

projecting respectively upward and downward from the junctions
of pedicles and laminae. They are forming the facet joints. The
facets on the superior processes are concave, and look backward
and medialward; those on the inferior are convex, and are directed
forward and lateralward.

Facet joints are synovial joints. They are just posterior to the
intervertebral foramen so it affects it very much. Its direction is
45 degrees on the sagittal plane and 90 degrees on the
horizontal plane.

The vertebral body of each lumbar vertebra is large, wider from

side to side than from front to back, and a little thicker in front
than in back. It is flattened or slightly concave above and below.
Its upper and lower surface is cortical bone and the inner
structure is cancellous bone. Between every two bodies there is
an intervertebral disc.

The intervertebral disc consists of annulus fibrosis (fibrous bag)

and the nucleus pulposus. The annulus fibrosis is multilaminar
and every lamina has its direction. Its postrolateral portion is
the thinnest portion. It may dysfunction in form of
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degeneration, bulge, protrusion, herniation(extrusion) and

sequestration.

2- 2-Ligamentous Structure

3-Musculature
a- Latismuss dorsi

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b- Erector Spinae
i- Multifidus

ii- Longissimus

iii- Iliocostalis Lumborum

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c- Transversospinals

d- Quadratus Lumborum

e- Abdominal muscles
i- Rectus abdominus

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ii- Obliqus Externus

iii- Obliqus Internus

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iv- Transversus Abdominis:

It acts as a stabilizer because of its fascial attachment
and because of its line of action

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Biomechanics of the Lumbar Spine

Osteokinematics:
Flexion:50

Extension:15

Lateral flexion:20

Axial rotation:5

Arthrokinematics:

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Facet Joint Arthrokinematics

Flexion:

Superior and anterior gliding

Extension:

Inferior glide

Lateral flexion:

Inferior glide(ipsilateral facet(

Superior glide(contralateral facet(

Axial rotation:

Separation(ipsilateral facet(

Approximation(contralateral facet).

Arthrokinematics of the body

With Extension

Shifting anterior

With flexion

Shifting posterior

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Fryette's Laws
1- Fryette's Law 1 :

Type 1 Mechanics, Neutral Mechanics, Fryette's First Principle

-When any part of the thoracic or lumbar spine is in a neutral

position, then sidebending of vertebrae will produce rotation in the
opposite direction

-Vertebrae will rotate into the side of the convexity

- The posterior facets and transverse processes become palpable

on the convex side of a lateral curve.

2- Fryette's Law 2 :
Type II Mechanics, Non-Neutral, Fryette's Second Principle

-Involves significant flexion or extension

-When any part of the thoracic or lumbar spine is in a non-neutral

position, then sidebending of vertebrae will produce rotation in the
same direction .

-Vertebrae will rotate into the side of the concavity.

-The posterior component (posterior transverse process) is on the

side of the concavity

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- Type II Dysfunction- Involves a single segment restriction

3- Fryette's Law 3 :

Initiating motion of a vertebral segment in any plane of

motion will modify the movement of that segment in the other
planes of motion

- Another way of saying this is that when motion is

introduced in the vertebral column in one direction, motion in all
other directions is reduced.

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Connective Tissue Manipulation

What is connective tissue?
Connective tissue (CT) is a kind of biological tissue that
supports, connects, or separates different types of tissues and
organs of the body. It is one of the four general classes of biological
tissues—the others of which are epithelial, muscular, and nervous
tissues.

All CT has three main components: cells, fibers, and

extracellular matrices, all immersed in the body fluids.

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Dense propper connective tissue is a special type of

connective tissue that includes tendons, ligaments and fascia,
capsule of joints,skin dermis and fibers forming the fibrous joints.

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Fascia … a special structure

Fascia is a structure of connective tissue that surrounds
muscles, groups of muscles, blood vessels, and nerves, binding
some structures together, while permitting others to slide
smoothly over each other. Various kinds of fascia may be
distinguished. They are classified according to their distinct layers,
their functions and their anatomical location: superficial fascia,
deep (or muscle)fascia, and visceral(or parietal) fascia.

Superficial fascia
This is found in the subcutis in most regions of the body,
blending with the reticular layer of the dermis. Within the
superficial fascia are found fat,vascular structures and nervous
tissues, particularly the pacinian corpuscles referred to as skin
receptor .The skin can be moved in many directions over the

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deeper structures because of the loosely knit nature of superficial

fascia.

Deep fascia
This is the dense fibrous connective tissue that
interpenetrates and surrounds the muscles, bones, nerves and
blood vessels of the body.

It is a very important structure because it gives the body its

shape.

Visceral Fascia
This suspends the organs within their cavities and wraps
them in layers of connective tissue membranes.

Examples : Peritoneum, pericardium,plura

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Anatomy of the thoracolumbar fascia

Biomechanical point
Fascia has the capacity to
changewhen subjected to
stress. This phenomena called
hysteresis. This follows the
strss strain curve.

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Trigger Points
Highly irritable localized spot of exquisite tenderness in a
nodule in a palpable taut band of (skeletal) muscle.

Evaluation
TART method

T Tenderness

A Asymmetry

R Restriction

T Texture

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Basic techniques
Direct Release

Hand over hand

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Anchor release technique

Cephalic release Caudal release

Cross hand Rotation release

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Active Release Technique (ART)

ART to get lumbar ART piriformis

SD Rt.,Rot Rt., Flex

ART iliopsoas

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Maitland Approach
Evaluation
Mobility testing includes:

1-Regional mobility

2-Passive Physiological Intersegmental Mobility

3-Passive Accessory InterVertebral Mobility ( PAIVM )

Considering Mobility and Pain.

Pain patterns include:

Release Pain : pain during or at the end of range indicating stiffness

Recovery Pain : Pain during "returning to neutral" indicating

instability

Latent Pain : Pain after at least three movements indicating mild

problem

After pain : Pain that continues after treatment indicating high

dose or wrong direction

Passive Physiological Intersegmental Mobility

Extension - Flexion

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Side bending

Rotation

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Passive Accessory InterVertebral Mobility ( PAIVM )

PACVP (postro anterior TVP (Transverse Vertebral
Intervertebral Pressure) Pressure

PAUM (postroanterior unilateral

IVP (InterVertebral Prssure)
mobility)

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Treatment Parameters
Time : 3 to 5 minutes

Grades :

Rhythm:

Sustained : begin with it in grade 3 to get ROM

Slow rhythmic : grade 1,2 to decrease pain and grade 3 to soften

motion gained by sustained mobilization

Staccato mobilization : Breaking down end range adhesions

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McKenzie Approach

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Table Procedures (not all in order of force progression)

 Extension principle – static

1. Lying prone
2. Lying prone in extension
3. Sustained extension
4. Posture correction
 Extension principle – dynamic
5. Extension in lying (with patient overpressure)
6a. Extension in lying with clinician overpressure
6b. Extension in lying with belt fixation
7. Extension mobilization (in neutral or in extension)
8. Extension manipulation
9. Extension in standing – EIS
10. Slouch-overcorrect.

 Extension principle with lateral component – dynamic

11. Extension in lying with hips off centre
12. Extension in lying with hips off centre with clinician
overpressure
13. Extension mobilization with hips off centre
14. Rotation mobilization in extension
15. Rotation manipulation in extension
 Lateral principle
16. Self-correction of lateral shift or side gliding
17. Manual correction of lateral shift
 Flexion principle
18. Flexion in lying – FIL
19. Flexion in sitting
20. Flexion in standing – FIS
21. Flexion in lying with clinician overpressure

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 Flexion principle with lateral component

22. Flexion in step standing – FISS
23. Rotation in flexion
24. Rotation mobilization in flexion
25. Rotation manipulation in flexion

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Mulligan Technique

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