Manual Mobilization of the Lumbar

and Thoracic Spine

Brian Vesci, MA, ATC
Hollie Walusz, MA, ATC
Stacey Hardin, PT, DPT, ATC
Stephanie Naylor, EdM, ATC
Objectives
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 Understand the osteo- and arthrokinematics of the

spine within the context of the clinical application of
joint mobilization.
 Identify physiologic implications leading to the
classification and treatment of patients shown to
benefit from high velocity low amplitude mobilizations.
 Instruct how to, and evaluate attendees’ ability to,
perform high velocity low amplitude thrust
mobilizations for the lumbar and thoracic spine,
allowing them to develop a plan to integrate these
techniques into their clinical practice.
Joint Mobilizations: Overview
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 Patient explanation
Joint Mobilizations: Overview
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 Patient explanation
 Identify anatomy of joint
Joint Mobilizations: Overview
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 Patient explanation
 Identify anatomy of joint
 Identify stable component
Joint Mobilizations: Overview
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 Patient explanation
 Identify anatomy of joint
 Identify stable component
 Identify mobilization
component
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Glide
Joint Mobilizations: Overview
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 Patient explanation
 Identify anatomy of joint
 Identify stable component
 Identify mobilization
component
 Patient positioning
Joint Mobilizations: Overview
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 Patient explanation  Clinician positioning

 Identify anatomy of joint (hand placement)
 Identify stable component
 Identify mobilization
component
 Patient positioning
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FINISH
Joint Mobilizations: Overview
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 Patient explanation  Clinician positioning

 Identify anatomy of joint (hand placement)
 Identify stable component  Direction of force
 Identify mobilization (restriction)
component
 Patient positioning
Joint Mobilizations: Overview
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 Patient explanation  Clinician positioning

 Identify anatomy of joint (hand placement)
 Identify stable component  Direction of force
 Identify mobilization (restriction)
component
 Treatment plane
 Patient positioning
Concave on Convex1
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Treatment Plane
Convex on Concave1
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Treatment Plane
Convex/Concave Rule:
Remix Edition
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 Brandt et al.2
 Evidence based review revealing translational motion in GH joint did
not always follow convex/concave rule

 My solution: Trust your physical exam

Joint Mobilizations: Overview
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 Patient explanation  Clinician positioning

 Identify anatomy of joint (hand placement)
 Identify stable component  Direction of force
 Identify mobilization (restriction)
component
 Treatment plane
 Patient positioning  Grade of mobilization3
Contraindications
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 Hypermobility  Disk Herniations

 Suspected factures  Open Wounds
 Instability  Malignancy


Clinician inexperience
Idiopathic pain
Immediate Post- Op
Infections


Acute Inflammation
Veterbral Basilar
Insufficiency
Defining Grades of Motion
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 Mobilization as a continuum – Maitland3

 Velocity
 Amplitude
 Position in available motion
 Grades3
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Resistance to
Movement

Normal
Joint
 Grades3
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Resistance to
I Movement

Normal
Joint
 Grades3
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Resistance to
I Movement

II
Normal
Joint
 Grades3
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Resistance to
I Movement

II
Normal
Joint
III
 Grades3
Boston University Slideshow Title Goes Here Normal Tissue
Resistance to
I Movement

II
Normal
Joint
III
IV
 Grades3
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Resistance to
I Movement

II
Pathologic
Joint
III
 Grades3
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Resistance to Restriction
I Movement

II
Pathologic
Joint
III
 Grades3
Boston University Slideshow Title Goes Here Normal Tissue Pathologic
Resistance to Restriction
I Movement

II
Pathologic
Joint
III
IV
 Grades3
Boston University Slideshow Title Goes Here Normal Tissue Pathologic
Resistance to Restriction
I Movement

II
Pathologic
Joint
III
IV
V
 Normal Tissue
I Resistance to
Movement
II
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Normal III
Joint
IV

I Pathologic
Restriction
II
Pathologic III
Joint
IV
V
 Normal Tissue
I Resistance to
Movement
II
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Normal III
Joint
IV

I Pathologic
Restriction
II
Pathologic III
Joint
IV
V
Lumbar – Arthrology4
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 Intralumbar apophyseal joints

Lumbar – Arthrokinematics5
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 Intralumbar
apophyseal joints
(L1-L5)
 flexion-extension
 rotation
 lateral flexion
Lumbar – Arthrokinematics4
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 Flexion
Lumbar – Arthrokinematics4
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 Extension
Lumbar – Arthrokinematics4
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 Axial rotation
Lumbar – Arthrokinematics4
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 Lateral flexion
Lumbar – Clinical Application
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 Imaging?
 Clinical prediction rule for mobilization6,7
 Duration < 16 days
 No symptoms distal to knee
 FABQ work subscale < 19
 ≥ 1 hypomobile lumbar spinal segment
 ≥ 1 hip with > 35°of internal rotation range of motion
 Patient positioning
Lumbar – Clinical Application4
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 Glides:
 Central posterior – anterior
 Unilateral posterior – anterior

 Anterior – posterior is not really an option. Solution?

Thoracic – Arthrology4
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 Intrathoracic apophyseal joints

 Costovetebral joints
Thoracic – Arthrokinematics5
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 Intrathoracic
apophyseal joints
(T1-T12)
 flexion-extension
 rotation
 lateral flexion
Thoracic – Arthrokinematics4
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 Flexion
Thoracic – Arthrokinematics4
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 Extension
Thoracic – Arthrokinematics4
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 Axial rotation
Thoracic – Arthrokinematics4
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 Lateral flexion
Thoracic – Clinical Application4
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 Soft tissue vs facet joint dysfunction

 Rib mobilization
 Proper breathing technique
Thoracic – Clinical Application4
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 Glides:
 Central posterior – anterior (PA glide)
 Unilateral posterior – anterior (PA glide)

 Anterior – posterior (AP glide) is not really an option.

Solution?
References
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1. Kaltenborn F, Evjenth O, Kaltenborn T, Morgan D, Vollowitz E. Manual Mobilization

of the Joints: Joint Examination and Basic Treatment. Vol 1. 4th ed. Oslo: Norli; 2007.

2. Brandt C, Sole G, Krause MW, Nel M. An evidence-based review on the validity of

the Kaltenborn rule as applied to the glenohumeral joint. Manual therapy.
2007;12(1):3-11.

3. Hengeveld E, Banks K, eds. Maitland's Vertebral Manipulation: Management of

Neuromusclar Disorders. Oberentfelden: Elsevier; 2014; No. 1.

4. Neumann D. Kinesiology of the Musculoskeletal System: Foundations for Physical

Rehabilitation. University of Michigan: Mosby; 2002.
References
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5. Group MM. Medical Illustration. 2006;

http://www.medicalmultimediagroup.com/content/medical-illustration. Accessed
December 14, 2015.

6. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients
with low back pain who demonstrate short-term improvement with spinal
manipulation. Spine. 2002;27(24):2835-2843.

7. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients
with low back pain most likely to benefit from spinal manipulation: a validation study.
Annals of internal medicine. 2004;141(12):920-928.