JOINT MOBILIZATION OF THE LUMBOPELVIC SPINE. PART 1

Cập nhật lần cuối vào 29/11/2022

Kỹ thuật di động khớp thắt lưng – chậu. Phần 1 trình bày phần ôn lại các đặc điểm giải phẫu, kỹ thuật di động khớp vùng thắt lưng. Phần 2 trình bày các kỹ thuật di động khớp cùng chậu.

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ANATOMY REVIEW

Bone and Joints

Terminology/Từ vựng:

• Vetebral body: thân đốt sống
• Tranverse process: mỏm ngang
• Spinous process: Mỏm gai
• Superior articular process: mỏm khớp trên
• ASIS: Gai chậu trước trên
• AIIS: Gai chậu trước dưới
• PSIS: Gai chậu sau trên
• Iliac crest: Mào chậu
• Sacroiliac ligament: Dây chằng cùng chậu

Physiologic (Osteokinematic) Motions of Lumbopelvic Spine

Lumbar (Facet) joint

• Lumbar flexion (forward bending): gập, cúi thắt lưng ra trước
• Lumbar spine extension (backward bending): duỗi, ưỡn ra sau
• Lumbar spine Side bending: Nghiêng bên cột sống thắt lưng
• Lumbar spine Rotation: Xoay cột sống thắt lưng

Coupled/Combined Motion (Vận động kết hợp)

• Lumbar SB & ROT occur contralaterally in neutral
• Lumbar SB & ROT occur ipsilaterally out of neutral
• Hip motion coupled with ilial (I/S) motion/ Vận động khớp háng kèm hợp với vận động xương chậu (chậu-cùng)
• Lumbar motion coupled with sacral (S/I) motion/ Vận động thắt lưng kèm với vận động xương cùng (cùng- chậu)
• Lumbar segmental maximal facet opening (R) occurs with FB, SB (L), ROT (R)/ Mở khớp facet ở vùng thắt lưng bên phải tối đa xảy ra khi cúi ra trước, nghiêng bên trái, xoay bên phải.
• Lumbar segmental maximal facet closing (R) occurs with BB, SB (R), ROT (L)/ Khoá khớp facet ở vùng thắt lưng bên phải xảy ra tối đa khi ngửa ra sau, nghiêng bên phải, xoay bên trái.

Viết tắt:

• FB: forward bending, nghiêng trước, gập
• BB:  backward bending, nghiêng sau, duỗi
• ROT: rotation, xoay
• SB: side bending: nghiêng bên
• flex/ext: gấp/duỗi
• IR/ER: xoay trong/xoay ngoài
• Innominate: (Xương) vô danh: là xương dính của xương chậu (illium), xương mu (pubis) và xương ngồi (ischium) một bên.
• Ghi chú gấp/duỗi cùng – chậu (S/I flexion/extension) còn có tên gọi là nutation/counternutation

Accessory (Arthrokinematic) Motions of the Lumbopelvic Spine

LUMBAR SPINE JOINT MOBILIZATIONS

Note: Current evidence suggests that the indications for use of joint mobilization techniques are multifactorial and may be based on direct assessment of mobility and an individual’s symptomatic response.

Central and Unilateral Anterior Glides (PA Glide)

Indications:

• To improve segmental mobility in all directions. 
• Central glides assist primarily with sagittal plane motion of forward and backward bending while unilateral glides enhance rotation and side bending.

Accessory Motion Technique

• Patient Position: 
  • Prone with a pillow supporting the lumbar spine. 
• Clinician Position & Hand Placement: 
  • Stand to the side of the patient.
  • As a general technique, stabilization is not required. 
  • The region of the hand just distal to the pisiform contacts the spinous process for central glides and the transverse process for unilateral glides while the mobilizing hand lies over the contact hand. The elbows are extended, and the forearms are in the direction in which force is applied. 
  • Alternate hand placement includes thumb-over-thumb pressure, or split finger contacts over the transverse processes of the same segment or the transverse processes of adjacent segments.
• Force Application: 
  • Anteriorly directed pressure is applied through hand contacts at either the spinous or transverse processes. 
  • Slight changes in force direction can be provided to improve specificity.

Lumbar Posterior to Anterior Glide

Accessory With Physiologic Motion Technique 

• Patient Position: 
  • seated, prone, quadruped, or standing position, (arms across the chest and a mobilization belt secured at the anterior aspect of the pelvis in sitting position). 
• Clinician Position & Hand Placement: 
  • standing behind or to side of pt
  • Place thumb over thumb contact or hypothenar eminence contact at the transverse process or spinous process of the segment to be mobilized with your forearm in line with the direction in which force is applied. 
  • For the quadruped forward-bending technique and the prone backward-bending technique, the region just distal to the pisiform of your mobilization hand is in contact with the transverse process or spinous process of the segment to be mobilized with your forearm in line with the direction in which force is applied. Your stabilizing arm is placed around the patient’s abdomen.
•  Force Application: 
  • As the patient actively moves into forward bending, backward bending, or rotation, apply force through your hand contacts in an anterior direction as the patient’s pelvis is stabilized by the mobilization belt. 
  • You move as the patient moves in order to maintain the proper force direction throughout the motion. Force is maintained throughout the range of motion and sustained at end range. 
  • For the quadruped forward bending technique, as the patient actively moves into forward bending by bringing the buttocks to the heels, apply an antero-superior force through your mobilization hand as your stabilization arm supports the abdomen. Shift your weight from one foot to the other as the patient moves in order to maintain the proper force direction throughout the motion. Force is maintained throughout the range of motion and sustained at end range. 
  • For the prone backward-bending technique, as the patient actively moves into backward bending by performing a prone press-up, apply an antero-superior force through your mobilization hand as your stabilization arm supports the abdomen. Shift your weight from one foot to the other as the patient moves in order to maintain the proper force direction throughout the motion. Force is maintained throughout the entire range of motion and sustained at end range. Self Mobilization is performed using a mobilization strap or towel placed over the segment to be mobilized, and force is applied while the patient performs active physiologic motion.

Physiologic Forward Bending

Indications:

• To improve physiologic segmental forward bending and/or to improve facet joint opening.

Accessory Motion Technique

• Patient Position: 
  • The patient is supine in a double knee to chest position. 
  • An alternate position: side-lying position with one third of the thigh over the edge of the table and the tibial tuberosity of the uppermost leg or both legs resting on your ASIS.
• Clinician Position & Hand Placement: 
  • You are standing in a straddle stance position at the side of the patient.
  • Prone position:
    • Your cephalad arm is placed at the anterior aspect of the patient’s bilateral knees in order to control motion and keep the patient’s knees close to the patient’s chest. 
    • Your caudal hand is placed over the inferior vertebra of the segment being mobilized.
  • Side-lying position: 
    • The cephalad hand stabilizes at the spinous or transverse processes of the superior aspect of the segment being mobilized. 
    • The caudal hand is placed across the sacrum with fingers contacting the spinous or transverse processes of the inferior aspect of the segment to be mobilized.
• Force Application: 
  • Both of your hand contacts work together to produce a scooping motion that brings the segment to be mobilized into forward bending. 
  • Your cephalad arm contact may resist the patient’s hip extension force followed by further mobilization into forward bending. In the side-lying position, the clinician shifts weight from the caudal to the cephalad leg, creating physiologic forward bending. 
  • Your stabilization hand maintains constant force as the mobilization hand localizes forward-bending forces to the segment being mobilized.

Accessory With Physiologic Motion Technique

• Patient Position: 
  • The patient is in a seated position to stabilize the pelvis. 
  • Quadruped or standing positions may also be used. 
  • A mobilization belt may be placed from the clinician to the anterior aspect of the patient’s pelvis to provide stabilization during force application. 
• Clinician Position & Hand Placement: 
  • the same as that which was described for the Central and Unilateral Anterior Glides Accessory With Physiologic Motion Technique
• Force Application: 
  • the same as that which was described for the Central and Unilateral Anterior Glides Accessory With Physiologic Motion Technique

Physiologic Backward Bending

Indications:

• To improve  physiologic segmental backward bending and/or to improve facet joint closing.

Accessory Motion Technique 

• Patient Position: 
  • side-lying position with the hips and knees flexed to the segment to be mobilized with one third of the patient’s thighs over the edge of the table and fixed on your ASIS. 
• Clinician Position & Hand Placement: 
  • Stand in a straddle stance position facing the patient.
  • The cephalad hand provides stabilization at the spinous or transverse processes of the superior aspect of the segment to be mobilized. 
  • The caudal hand maintains the patient’s flexed knees against the clinician’s ASIS.
• Force Application: 
  • Apply force through the long axis of the patient’s thigh as you stabilize the superior aspect of the segment to which mobilization force is being directed.

Accessory With Physiologic Motion Technique

• Patient Position: 
  • Sitting position to stabilize the pelvis. 
  • Prone or standing positions may also be used. 
  • A mobilization belt may be placed from the clinician to the anterior aspect of the patient’s pelvis to provide stabilization during force application.
• Clinician Position & Hand Placement: 
  • You are standing behind or to the side of the patient.
  • Hand placement is the same as that which was described for the Central and Unilateral Anterior Glides Accessory With Physiologic Motion Technique.
• Force Application: 
  • Force application is the same as that which was described for the Central and Unilateral Anterior Glides Accessory With Physiologic Motion Technique.

Physiologic Side Bending With Finger Block

Indications:

• To improve  physiologic segmental side bending and/or to improve facet joint opening or closing.

Accessory Motion Technique

• Patient Position: 
  • Prone position with a pillow supporting the lumbar spine. 
  • Alternately, the patient is in a side-lying position with one third of the thighs over edge of table and resting on your anterior leg.
• Clinician Position & Hand Placement: 
  • You are in a straddle stance position at the side of the patient. 
  • Your mobilization hand grasps the patient’s closest leg just proximal to the knee with the patient’s knee flexed or extended. Digits 2 and 3 or the thumb of your stabilization hand is placed along the side of the spinous process of the superior vertebra of the segment being mobilized on the side that you are standing. 
  • In the side lying position, digits 2 and 3 or the thumb of your stabilization hand is placed at the upper side of the spinous process of the superior vertebra of the segment being mobilized and your other hand grasps the patient’s ankles, which support the patient’s flexed knees against your leg.
• Force Application: 
  • Move the patient’s leg into abduction until movement arrives at the segment being mobilized. Force is localized by providing a finger block to the superior aspect of the target segment. 
  • In the side lying position, move the patient’s legs up or down creating rotation of the hips and subsequent sidebending of the lumbar spine. Recruit motion to the segment being mobilized and block movement with your stabilization hand for the purpose of localizing forces. Force is delivered to the segment to be mobilized by imparting motion to the lumbar spine through the leg. 
  • A prolonged stretch or oscillations are performed by moving the patient’s leg against the blocked segment.

Accessory With Physiologic Motion Technique

• Patient Position: 
  • The patient is in a sitting position to stabilize the pelvis with arms crossed.
  • A mobilization belt may be placed from the clinician to the anterior aspect of the patient’s pelvis to provide stabilization during force application
• Clinician Position & Hand Placement: 
  • You are standing at the side of the patient.
  • With one arm woven through the patient’s folded arms to control trunk movement into side bending, the other hand provides the finger block. 
  • Your finger or thumb is placed to the side of the spinous process immediately inferior to the segment to be mobilized on the side ipsilateral to the direction of side bending.
• Force Application: 
  • The finger block is maintained while the patient performs active side bending as you control and assist this motion down to the segment to be mobilized. 
  • Force is maintained throughout the entire range of motion and sustained at end range. A sustained hold and/or oscillations may be performed at end range.

Physiologic Rotation With Finger Block

Indications:

• To improve physiologic segmental rotation and/or to improve facet joint opening or closing.

Accessory Motion Technique

• Patient Position: 
  • Technique 1: Prone with pillow supporting lumbar spine with knees extended or flexed 
  • Technique 2: Sitting with arms folded across chest
• Clinician Position & Hand Placement: 
  • Stand to the side of the patient.
  • Stabilizing contact:
    • Technique 1: Finger or thumb block provided at side of superior spinous process of segment to be mobilized
    • Technique 2: Finger or thumb block provided at side of inferior spinous process of segment to be mobilized on side contralateral to direction of ROT or on transverse process of side ipsilateral to direction of ROT
  • Mobilizing contact:
    • Technique 1: With knees flexed, clinician grasps pt’s ankles in order to induce movement or mobilizing forearm moves gluteals aside as hand grasps ASIS
    • Technique 2: Arm weaves through pt’s folded arms with hand resting on contralateral shoulder.
• Force Application: 
  • Your mobilization hand contact at the patient’s ASIS imparts an upward force through the pelvis, which creates lumbar rotation at the segment to be mobilized. 
  • Alternately, lumbar rotational forces are produced through movement of the legs from side to side. 
  • A sustained hold and/or oscillations are performed by moving the pelvis or legs against the blocked segment.

Accessory With Physiologic Motion Technique 

• Patient Position: 
  • Sitting position to stabilize the pelvis with arms crossed. 
  • A mobilization belt may be placed from the clinician to the anterior aspect of the patient’s pelvis to provide stabilization during force application. 
• Clinician Position & Hand Placement: 
  • Stand at the side of the patient.
  • With one arm woven through the patient’s folded arms to control trunk movement into rotation, the other hand provides the finger block. 
  • Your finger or thumb is placed to the side of the spinous process immediately inferior to the segment to be mobilized on the side contralateral to the direction of rotation or on the transverse process on the side ipsilateral to the direction of rotation.
• Force Application: 
  • The finger block is maintained while the patient performs active rotation as you control and assist this motion down to the segment to be mobilized. 
  • Force is maintained throughout the entire range of motion and sustained at end range. A sustained hold and/or oscillations may be performed at end range.

More pictures:

Trunk Manipulation

References:

• Christopher H. Wise, Dawn T. Gulick. Mobilization Notes: Rehabilitation Specialist’s Pocket Guide. F. A. Davis Company, 2009.
• Christopher H. Wise. Orthopaedic Manual Physical Therapy: FROM ART TO EVIDENCE. F. A. Davis Company. 2015.
• Carolyn Kisner, Lynn Allen Colby, John Borstad. Therapeutic exercise : foundations and techniques, Seventh edition. F.A. Davis Company. 2018