JOINT MOBILIZATION OF THE LUMBOPELVIC SPINE. PART2

Cập nhật lần cuối vào 17/03/2023

Kỹ thuật di động khớp thắt lưng – chậu. Phần 2 trình bày các kỹ thuật di động khớp cùng chậu.

XEM LẠI: JOINT MOBILIZATION OF THE LUMBOPELVIC SPINE. PART 1

ANATOMY REVIEW

Motions of SI JOINT

SI joint/ Khớp cùng chậu

• Iliosacral (I/S) motion: Motion of ilium in reference to sacrum/ Vận động chậu- cùng: vận động của xương chậu so với xương cùng
• Sacroilial (S/I) motion: Motion of sacrum in reference to ilium/ Vận động cùng -chậu: vận động của xương cùng so với xương chậu
  • Reference for lumbar motion is superior vertebra of motion segment/ Tham chiếu vận động thắt lưng là đốt sống phía trên của đoạn vận động
  • Reference for I/S motion is ASIS/ Tham chiếu của vận động chậụ- cùng là ASIS
  • Reference for S/I motion is anterior base of sacrum/ Tham chiếu của vận động cùng- chậu là đáy xương cùng
• I/S anterior/posterior ROT (tilt, xoay hoặc nghiêng chậu- cùng ra trước/ra sau): Motion of ASIS anterior/inferior & posterior/superior in sagittal plane/ Vận động ASIS ra trước/xuống dưới và ra sau/lên trên
• I/S inflare/outflare (Ép vào/Xoè ra chậu- cùng): Motion of ASIS medially & laterally in transverse plane/ Vận động ASIS vào trong và ra ngoài ở mặt phẳng ngang.
• I/S upslip/downslip (trượt chậu-cùng lên trên/xuống dưới chậu- cùng): Motion of ASIS superiorly & inferiorly in frontal plane/Vận động ASIS lên trên và xuống dưới ở mặt phẳng trán
• S/I flexion/extension (nutation/counternutation, gấp/duỗi cùng – chậu): Motion of sacral base anterior & posterior in sagittal plane
• S/I SB (nghiêng bên khớp cùng – chậu): Motion of sacral base in frontal plane
• S/I ROT: Motion of sacral base in transverse plane
• S/I forward/backward torsion: Triplanar motion of sacral sulcus anteriorly & posteriorly about an oblique axis

Coupled/Combined Motion

• Hip motion coupled with ilial (I/S) motion
• Lumbar motion coupled with sacral (S/I) motion

XEM LẠI: GIẢI PHẪU CHỨC NĂNG VÙNG CHẬU-HÔNG. XƯƠNG VÀ KHỚP

SACROILIAC JOINT MOBILIZATIONS

Iliosacral Anterior/Posterior Rotation Isometric Mobilization

Indications: 

• Iliosacral anterior rotation mobilization:To improve IS anterior rotation or in the presence of a posteriorly rotated innominate positional fault. 
• Iliosacral posterior rotation mobilization: To improve  IS posterior rotation or in the presence of an anteriorly rotated innominate positional fault.

Technique:

• Patient Position:
  • Supine with the hips in a variable degree of flexion. 
• Clinician Position & Hand Placement:
  • Stand at the side of the patient.
  • Mobilization hand: placed at the anterior aspect of the distal thigh to mobilize the pelvis into anterior rotation and at the posterior aspect of the distal thigh to mobilize the pelvis into posterior rotation. 
  • Stabilization hand: provides counterforce on the alternate side of the contralateral thigh.
• Force Application:
  • Use simultaneous force/counterforce by applying equal force through both hand contacts, simultaneously. 
  • Resisted isometric contraction of the hip flexors imparts an anterior rotation force to the pelvis, and resisted isometric contraction of the hip extensors imparts a posterior rotation force.

Iliosacral P/A Rotation Isometric Mobilization

Iliosacral Anterior Rotation

Indications: 

• To improve  IS anterior rotation or in the presence of a posteriorly rotated innominate positional fault.         

Accessory Motion Technique 

• Patient Position:
  • Prone position in a diagonal orientation on the table with one foot on the floor. 
  • Stabilization of the contralateral pelvis is provided through the patient’s foot in contact with the floor. 
• Clinician Position & Hand Placement:
  • You are in a stride stance position facing the same direction as the patient.
  • Your caudal hand grasps the distal aspect of the patient’s anterior thigh just proximal to the knee 
  • the hypothenar eminence of your cephalad hand contacts the posterior superior iliac spine on the side being mobilized with your forearm in line with the direction in which force is applied.
• Force Application:
  • Your caudal hand moves the patient’s hip into extension as your cephalad hand applies an anterior superior force through the posterior superior iliac spine.
  • Between each progression, the patient may impart an isometric hip flexion force into your caudal hand contact at the anterior thigh for the purpose of utilizing the hip flexors to impart an additional anterior rotatory force followed by further movement of the hip into extension with simultaneous anterosuperior mobilization force provided by your cephalad hand.

Iliosacral Anterior Rotation

Accessory With Physiologic Motion Technique

• Patient Position:
  • Standing in a lunge or half-kneeling position with the leg on the side being mobilized placed behind the other leg. 
• Clinician Position & Hand Placement:
  • Standing contralateral to the side being mobilized in a straddle stance position prepared to move as the patient moves.
  • Your stabilization arm and hand is placed over the patient’s abdomen 
  • Your mobilization hand is placed at the PSIS with your arm in line with the direction of force.
• Force Application:
  • The patient gently shifts weight from the back leg to the front leg producing hip extension on the side being mobilized. 
  • This motion is performed as you impart an anteriorly-directed force through your PSIS contact while maintaining stabilization at the abdomen. 
  • Force is maintained throughout the entire range of motion and sustained at end range.

Iliosacral Posterior Rotation

Indications:

• To improve  IS posterior rotation or in the presence of an anteriorly rotated innominate positional fault.

Accessory Motion Technique

• Patient Position:
  • The patient is in a side-lying position facing you with the side to be mobilized uppermost and the hip flexed to 90⁰. 
• Clinician Position & Hand Placement:
  • Standing in a straddle stance position facing the patient with the posterior aspect of the uppermost thigh against your trunk.
  • Stabilization is provided by maintaining the patient’s contralateral hip in neutral and in contact with the table. 
  • The palm of your cephalad hand contacts the patient’s ASIS and 
  • the palm of your caudal hand contacts the patient’s ischial tuberosity on the side being mobilized, with your forearms in opposite directions in line with the direction in which force is applied.
• Force Application:
  • Move the patient’s hip into flexion. After taking up the slack in the joint, apply equal and opposite forces through both of your hand contacts. 
  • Between each progression, the patient may impart an isometric hip extension force into your trunk for the purpose of utilizing the hip extensors to impart an additional posterior rotatory force followed by further movement of the hip into flexion with simultaneous mobilization force provided through your hand contacts.

Iliosacral Posterior Rotation

Accessory With Physiologic Motion Technique

• Patient Position:
  • Standing position. 
• Clinician Position & Hand Placement:
  • Stand contralateral to the side being mobilized in a straddle stance position prepared to move as the patient moves.
  • Your stabilization hand is placed over the patient’s sacrum and 
  • Your mobilization hand is placed at the ASIS with your arm in line with the direction of force.
• Force Application:
  • The patient actively flexes the hip on the side being mobilized. 
  • This motion is performed as you impart a posteriorly directed force through your ASIS contact while maintaining stabilization at the sacrum. 
  • Force is maintained throughout the entire range of motion and sustained at end range.

Iliosacral Downslip (Trượt chậu- cùng xuống dưới)

Indications:

• To improve mobility or in the presence of an upslip positional fault of the innominate.

Accessory Motion Technique 

• Patient Position:
  • Supine position when mobilization into posterior rotation is also being performed,
  •  or prone when mobilization into anterior rotation is also being performed. The hip is pre-positioned in adduction and internal rotation. 
  • Alternately, the patient is side-lying with the side being mobilized uppermost. 
• Clinician Position & Hand Placement:
  • Stand in a straddle stance position at the foot of the patient facing cephalad.
  • Stabilization is provided by the patient’s weight. 
  • Both of your hands grasp the distal leg just proximal to the ankle or proximal to the knee as required with your forearms in the direction in which force is applied. 
  • Your hand contacts may be reinforced by placing the mobilization belt in a figure eight. 
  • When the patient is side-lying, your cephalad hand grasps the uppermost iliac crest.  
• Force Application:
  • Shift your weight from the front leg to the back leg while maintaining your hand contacts. 
  • With patient side-lying, impart a caudal force through the hand contact. 
  • Perform sustained hold and/or oscillations as indicated.

Accessory With Physiologic Motion Technique

• Patient Position:
  • Standing on a step with leg on the side being mobilized off of the step. 
• Clinician Position & Hand Placement:
  • Kneel at the front, back, or side of the patient.
  • With both hands, grasp the distal aspect of the leg on the side being mobilized.
• Force Application:
  • Apply a caudally directed force through the leg on the side being mobilized and subsequently through the pelvis. 
  • An alternate technique involves the patient in a side-lying position with the patient actively producing pelvic downslip during application of force by the clinician through the iliac crest. 
  • Force is maintained throughout the entire range of motion and sustained at end range.

Iliosacral Outflare/Inflare

Indications:

• To improve mobility or a positional fault of the innominate in lateral & medial direction, which occurs as accessory movement of hip ER & IR, respectively
• In presence of positional fault of innominate

Accessory Motion Technique 

• Patient Position:
  • Supine position with the hips in neutral. 
• Clinician Position & Hand Placement:
  • Stand on the side of the patient being mobilized for outflare and on the contralataral side for inflare.
  • Stabilization is provided by the patient’s weight. 
  • For outflare, one hand grasps the medial aspect of the patient’s ASIS as the other grasps the PSIS. 
  • For inflare, one hand grasps the lateral aspect of the ASIS as the other hand grasps the PSIS. 
  • Your forearms are in the direction in which force is applied.
• Force Application:
  • For outflare : Apply force through both hand contacts moving the ASIS laterally and PSIS medially 
  • For inflare:  Apply force through both hand contacts moving the ASIS medially and PSIS laterally 

Accessory With Physiologic Motion Technique

• Patient Position:
  • Standing position. 
• Clinician Position & Hand Placement:
  • Stand contralateral to the side being mobilized.
  • For outflare, the stabilization hand contacts the PSIS or sacrum, and the mobilization hand contacts the medial aspect of ASIS. 
  • For inflare, the stabilization arm is placed across the abdomen, and the mobilization hand contacts the lateral aspect of the ASIS.
• Force Application:
  • For outflare, the patient performs hip ER as force is applied through the ASIS in a posterolateral direction with sacral stabilization. 
  • For inflare, the patient performs hip IR as force is applied through the ASIS in an anteromedial direction with abdominal stabilization.

Sacroilial Forward and Backward Bending (Gập cùng- chậu ra trước và ra sau)

• To improve mobility of sacrum into FB & BB which is a coupled motion of lumbar BB & FB, respectively
• In presence of a positional fault of sacrum

Accessory Motion Technique 

• Patient Position:
  • Prone position, with the hips in ER for sacroilial forward bending and IR for sacroilial backward bending. 
• Clinician Position & Hand Placement:
  • Stand at the side of the patient.
  • Stabilization is provided by patient’s weight. 
  • For sacroilial forward bending, the aspect of the hand just distal to your pisiform or thumb over thumb contacts the base of the sacrum. 
  • For sacroilial backward bending, the aspect of the hand just distal to your pisiform or thumb over thumb contacts the apex of the sacrum. 
  • Your forearms are in the direction in which force is applied.
• Force Application:
  • Apply force through your hand contacts. 
  • Sacroilial forward bending mobilization may be timed with expiration and sacroilial backward bending mobilization may be timed with inspiration.

 

Accessory With Physiologic Motion Technique 

• Patient Position:
  • Sitting or standing position. 
• Clinician Position & Hand Placement:
  • Stand or squat behind the patient.
  • Stabilization is provided to the ilium as the patient is in a sitting position. 
  • Stabilization may also be provided by placing your arm across the patient’s abdomen. 
  • Thumb over thumb contact or the region just distal to the pisiform is placed
    • at the sacral base for overpressure into sacroilial forward bending or counterpressure for sacroilial backward bending 
    • or at the sacral apex for overpressure into sacroilial backward bending or counterpressure for sacroilial forward bending.
• Force Application:
  • For sacroilial forward bending, the patient actively moves into lumbar backward bending as you impart force through your contact at the base of the sacrum for overpressure or at the apex of the sacrum for counterpressure. 
  • For sacroilial backward bending, the patient actively moves into lumbar forward bending as force is imparted through your contact at the apex of the sacrum for overpressure or at the base of the sacrum for counterpressure. 
  • Force is maintained throughout the entire range of motion and sustained at end range. 

• Selfmobilization for sacroilial forward bending or backward bending may be performed using fist pressure or ball and mobilization strap.

Sacroilial Forward and Backward Torsion

Indications:

• To improve mobility of sacrum into forward & backward torsion, coupled with lumbar motion
• In presence of a positional fault of the sacrum.

Accessory Motion Technique

• Patient Position:
  • Prone with the hip in ER on the side to which a forward torsion mobilization is being performed and with the hip in IR on the side to which a backward torsion mobilization is being performed. 
• Clinician Position & Hand Placement:
  • Stand behind or contralateral to the side being mobilized.
  • Stabilization hand:
    • For sacroilial forward torsion, your stabilization hand contacts the ASIS on the side being mobilized. 
    • For sacroilial backward torsion, your stabilization hand contacts the PSIS on the side being mobilized. 
  • Mobilization hand:
    • For sacroilial forward torsion, the aspect of the hand just distal to your pisiform or thumb of your mobilization hand contacts the sacral sulcus on the side being mobilized. 
    • For sacroilial backward torsion, the aspect of the hand just distal to your pisiform or thumb contacts the sacral inferior lateral angle contralateral to the side being mobilized.
• Force Application:
  • Apply force through your mobilization hand contact while maintaining stabilization. 
  • Sacroilial forward torsion mobilizations may be timed with expiration and 
  • Sacroilial backward torsion mobilizations may be timed with inspiration.

Accessory With Physiologic Motion Technique 

• Patient Position:
  • Sitting or standing position. 
• Clinician Position & Hand Placement:
  • Stand or squat behind the patient.
  • Stabilization is provided to the ilium as the patient is in a sitting position. 
  • Stabilization may also be provided by placing your arm across the patient’s abdomen. 
  • Thumb over thumb contact or the region just distal to your pisiform is placed
    • at the right or left sacral sulcus for overpressure into left or right sacroilial forward torsion, respectively, 
    • or counterpressure for right or left sacroilial forward torsion, respectively. 
  • Thumb over thumb contact or the region just distal to your pisiform is placed
    • at the right or left sacral inferior lateral angle for overpressure into left or right sacroilial backward torsion, respectively, 
    • or counterpressure for right or left sacroilial backward torsion, respectively. 
  • Your forearm is in line with the direction in which force is applied.
• Force Application:
  • For sacroilial forward torsion, the patient actively moves into rotation as you impart force through your contact at the contralateral sacral sulcus for overpressure or at the ipsilateral sacral sulcus for counterpressure. 
  • For sacroilial backward torsion, the patient actively moves into rotation as you impart force through your contact at the contralateral inferior lateral angle of the sacrum for overpressure or at the ipsilateral inferior lateral angle of the sacrum for counterpressure. 
  • Force is maintained throughout the entire range of motion and sustained at end range.

Lumbar Rotation Mobilization With Ligamentous Tension Locking High-Velocity Thrust

Indications: 

• To improve unilateral opening of a segment, 
• To provide symptomatic relief, or 
• To restore a segment to a neutral position. 

Ligamentous tension locking increases the specificity of this procedure.

Technique:

• Patient Position:
  • The patient is in a right side- lying position facing you with both hips and knees flexed. The patient is close enough to you to allow 1/3 of the thighs to be placed over the edge of the table. The patient set-up is as follows:
    • You place the patient’s knee of the upper leg in contact with your ASIS.
    • Supporting the patient’s upper leg with your caudal hand, move from left to right while palpating with your cephalad hand for motion to arrive at the lumbar interspinous space of the segment being mobilized.
    • Once motion is felt to arrive at the desired segment, the patient’s foot of the upper leg is placed behind the knee of the lower leg for stabilization.
    • Your caudal hand is now moved to the Interspinous Space to monitor motion as your cephalad hand grasps the patient’s lower arm and gently pulls toward the ceiling thus producing rotation down to the desired segment.
• Clinician Position & Hand Placement:
  • You are in a straddle stance position facing the patient. 
  • Your caudal hand is placed at the patient’s posterior buttock and your cephalad hand weaves through the patient’s upper arm in order to allow your cephalad hand to produce a skin lock with the caudal hand as your cephalad hand fingers are placed at the upper side of the spinous process of the superior vertebra of the segment being mobilized and the fingers of your caudal hand block the underside of the spinous process of the inferior vertebra of the segment being mobilized. 
  • An alternate hand contact uses the caudal forearm at the gluteals.
• Force Application:
  • With all hand contacts in place, the patient is rotated toward you to place the trunk in a position that is perpendicular to the table. Slack is taken up until the ligamentous tension lock is engaged. 
  • Force is then applied by either your cephalad arm contact through the patient’s trunk while the caudal arm blocks at the pelvis or vice versa. 
  • The patient takes a deep breath and as they slowly exhale, slack is taken up and a high-velocity low amplitude thrust is delivered at end range. 
  • Alternately, using the gluteal contact, force is delivered superiorly and anteriorly in order to close the involved segment.

 

Lumbar Rotation Mobilization

Lumbopelvic Regional High-Velocity Thrust

Indications: 

• To improve the lumbopelvic region and for symptomatic relief of low back pain. 

Technique:

• Patient Position:
  • Supine & side bent away from clinician
  • While maintaining SB, pt’s trunk lifted & rotated with shoulder planted onto table
• Clinician Position & Hand Placement:
  • Standing on side contralateral to one to be mobilized
  • Your caudal hand contact is placed at the patient’s contralateral ASIS with your forearm in the direction of force and your cephalad hand is weaved through the patient’s arms or contacts the posterior aspect of the patient’s contralateral scapula.
• Force Application:
  • Your hand contact at the patient’s arms or scapula rotates the patient’s trunk toward you until you feel motion arrive at the patient’s ASIS. 
  • Once motion arrives at the ASIS, cease further rotation. While maintaining this position, impart a high-velocity low-amplitude thrust in a posterior direction through your hand contact at the patient’s ASIS.

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
  

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