Lumbar Spine

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Lumbar Spine
• Superior facets face antero-laterally
• Inferior facets face postero-medially
• Orientation facilitates flex/ext & SF, limits
rotation
• CPP: extension
• CP: SF/rot > extension

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Lumbar Spine: Arthrokinematics
• Flexion: supero-anterior glide
• Extension: infero-posterior glide

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Lumbar Spine: Arthrokinematics
• SF: ipsi facet glides infero-posterior
contra facet glides supero-anterior

• Rotation: ipsi facet distracted

contra facet compressed

R rotation
LSF

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Lumbar Spine
Biomechanical Ax & Rx
Biomechanical Ax

If from the SCAN your hypothesis is HYPOMOBILITY

• What should we assess?

• AROM + OP, H & I

• PPIVM
• Passive Accessory Glides
• PAIVM
PPIVMs: Bilateral Flexion
❑ Pt: Side lying with hips/knee flexed
❑ Pht:
✓ Facing pt

✓ Pt’s knees supported on Pht’s thigh

✓ Caudal hand hold legs

✓ Cranial hand palpate 2 adjacent SP

✓ Bring Lx spine into flexion

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 PPIVMs: Bilateral Extension
❑ Pt: Side lying, with hips/knee flexed
❑ Pht:
✓ Facing pt

✓ Pt’s knees supported on table or on Pht’s thigh

✓ Caudal hand hold legs

✓ Cranial hand palpate 2 adjacent SP

✓ Bring Lx into extension

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 PPIVMs: Side Flexion
❑ Pt: Side lying, with hips/knee flexed
❑ Pht:
✓ Facing pt
✓ Pt’s knees supported on table
✓ Caudal hand on pelvic either on greater trochanter
or with forearm between trochanter and iliac crest
✓ Cranial hand palpate 2 adjacent SP
✓ Bring Lx into side flexion towards the ceiling

(see “Lx SF PPIVM” video on Stream)

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 PPIVMs: Unilateral Flexion
❑ Pt: Side lying, with hips/knee slightly flexed
❑ Pht:
✓ Facing pt
✓ Pt’s knees supported on table
✓ Keep Lx spine in neutral position
✓ Caudal hand/FA between iliac crest & greater
trochanter
✓ Cranial hand palp 2 adjacent SP
✓ Bring Lx into unilat flexion

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 PPIVMs: Unilateral Extension
❑ Pt: Side lying, with hips/knee flexed
❑ Pht:
✓ Facing pt

✓ Pt’s knees supported on table

✓ Lx spine in neutral position

✓ Caudal hand/FA between iliac crest & greater

trochanter

✓ Cranial hand palpate 2 adjacent SP

✓ Bring Lx spine into unilateral ext

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 PPIVMs: Unilateral Extension
Thoracolumbar junction
❑ Pt: Side lying, with hips/knee flexed
❑ Pht:
✓ Facing pt

✓ Pt’s knees supported on table

✓ Lx spine in neutral position

✓ Caudal hand stabilizes SP (table-side of inferior segment)

✓ Cranial hand on pt’s shoulder

✓ Via shoulder, pht mobilizes pt’s trunk into rotation

(extension will occur naturally)

(see video “unilateral thoracolumbar extension” on Stream)

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Biomechanical Ax

If from the SCAN your hypothesis is HYPERMOBILITY/INSTABILITY

• What should we assess?

• Neuromuscular Control tests: ASLR, prone ASLR, TrA, Multifidus

• Directional Stability tests
Directional Stability Tests
❑ Traction

❑ Compression

❑ Translation

❑ Anterior

❑ Posterior

❑ Lateral

❑ Torsion

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Directional Stability: General Traction
❑ Pt:
❑ Supine

❑ Hips & Knees flexed

❑ Feet close to the edge of bed

❑ Pht:
❑ Create traction vector

❑ Hold 5 sec, assess for pain, gap & EF

(pain provocation test)

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Directional Stability: Traction
❑ Pt:
❑ Side lying
❑ Lx spine in neutral
❑ Hips & Knees flexed
❑ Pht:
❑ Cranial hand: stabilize SP of superior segment
❑ Caudal hand: hold SP of inferior segment
❑ Apply a traction force to inferior segment
❑ Hold 5 sec, assess for pain, gap & EF
(see « L4L5 Traction & Compression » video on stream)

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Directional Stability: General Compression
❑ Pt: Supine (or side lying); hips & knees flexed

❑ Pht:

❑ Using forearm, apply a compression force to the ischial tuberosities

❑ Hold 5 sec, assess for pain, gap & EF

(pain provocation test)

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Directional Stability: Compression
❑ Pt:
❑ Side lying
❑ Lx spine in neutral
❑ Hips & Knees flexed
❑ Pht:
❑ Cranial hand: stabilize SP of superior segment
❑ Caudal hand: hold SP of inferior segment
❑ Apply a compression force to inferior segment
❑ Hold 5 sec, assess for pain, gap & EF
(see « L4L5 Traction & Compression » video on stream)

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 Directional Stability: Anterior translation
❑ Pt: side lying with hip flexed
❑ Pht:
❑ Support the pt’s knees with hip
❑ Cranial hand: stabilize SP of superior segment
❑ Caudal hand: palpate SP of inferior segment or holds pt’s shins
❑ Apply a post translation force to inferior segment by pushing pt’s legs
posteriorly
❑ Hold 5 sec, assess for pain, gap & EF

❖ Relative anterior translation of the superior segment

❖ If (+)ve – repeat in flexion (lig integrity); in extension (bony integrity)

(see “L4L5 anterior translation” video on stream)

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Directional Stability: Posterior translation
(Option 1)
❑ Pt: sitting at edge of bed; with F/As together (on pht’s shoulders)
❑ Pht:
❑ Standing, facing pt
❑ Palpate SP of superior segment while stabilizing SP of inferior segment
❑ Instruct pt to gently press their F/As into the pht’s shoulder
❑ Hold 5 sec, assess for pain, gap & EF

(see « L4L5 dynamic posterior translation » video on stream)

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 Directional Stability: Posterior translation
(Option 2)
❑ Pt: sitting at edge of bed; Lx spine in neutral; FA ipsilateral to pht
on ant inf ribs
❑ Pht:
❑ Standing
❑ Caudal index & middle fingers stabilize the SP inferior segment
❑ Cranial FA on pt’s FA (mirroring level of superior segment)
❑ Perform a posterior translation force
❑ Hold 5 sec, assess for pain, gap & EF

❖ If (+)ve in neutral, assess in flexion (lig integrity) &

in extension (bony integrity)

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 Directional Stability: Lateral translation
❑ Pt: sitting at edge of bed with arms crossed
❑ Pht:
❑ Standing at the side of the bed
❑ Caudal hand: stabilize the inferior segment
laterally
❑ Cranial hand: palpate the superior segment
(with arm around pt’s trunk)
❑ Apply a lateral translation force
❑ Hold 5 sec, assess for pain, gap & EF
(see « L4L5 L translation » video on stream)

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 Directional Stability: Farfan Torsion Test
Right example
❑ Pt in prone
❑ Pht:
❑ Cranial hand: use thumb to stabilize right side of SP of superior segment
❑ Caudal hand: palpate L ASIS
❑ Apply a torsion force through the L ASIS by pulling it towards the ceiling,
creating a relative right rotation vector
❑ Hold 5 sec, assess for pain, gap & EF
(see “Farfan” video on stream)

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 Directional Stability: Torsion/rotation
✓ More specific than Farfan test
Right torsion example
❑ Pt in left side lying with hips flexed
❑ Pht:
❑ Standing facing pt
❑ Cranial hand: Use thumb to stabilize right side of SP of superior
segment
❑ Caudal hand: Palpate L side of SP of inferior segment
❑ Apply a torsion force through the inferior segment by pulling
SP towards the ceiling
❑ Hold 5 sec, assess for pain, gap & EF

❖ Ax in neutral & in EOR of rotation

(see « L4L5 R torsion test » video on stream)

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Lumbar Spine
Treatment

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Locking Techniques
When performing lumbar PPIVMs, “locking” the segments above/below the segment you are
mobilizing will help:

1) protect unstable/irritable segments

2) increase specificity and efficacy of PPIVM technique
3) maximize safety prior to manipulation

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 ❑ Can involve ipsi OR contra SF (ipsi/contra to the side you
are mobilizing ie ceiling-side)
❑ Can involve flexion OR extension
❑ Will always involve rotation contralateral to the side the pt
is lying on

Locking From Technique: from a SL position, pht pulls on pt’s inferior arm
Above (table-side arm) to guide segments above the one
to be treated into locked position:

- Flexion: pull arm straight out (perpendicular to trunk),

parallel to floor
- Extension: pull arm straight up to ceiling
- Contra SF: pull arm towards pt’s feet, parallel to floor
- Ipsi SF: pull arm towards pt’s head, parallel to floor

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 Ex: If pt is in left side lying, lock will invariably involve right
rotation;

→ If we induce RSF, this creates a congruent, physiological

end-range lock
→If we induce LSF, this creates an incongruent, facet lock
Locking From → We can choose to add a vector of flexion or extension to
“prime” the segment we are working on into
Above flexion/extension prior to mobilizing

❑ Combinations of flexion/contra SF/ipsi rot (flexion lock)

and extension/ipsi SF/ipsi rot (extension lock) most
commonly used in clinic

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 Locking From
Above: Flexion
Lock
Created via the summation
of 2 vectors:

1) Flexion (perpendicular to
trunk & parallel to floor)
2) Contra SF (twds pt’s feet, Contra SF
parallel to floor)

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Locking From Above:
Extension Lock
Created via the summation
of 2 vectors:

1) Extension (towards ceiling)

2) Ipsi SF (twds pt’s head, parallel to floor)
ext
Ipsi SF

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Locking From ❑ Ligamentous lock created by bringing inferior segments
into either bilat flexion or bilateral extension
Below ❑ Can choose to then offset legs to then induce ipsi or contra
SF from below

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Locking From Below
✓ Perform bilat flexion PPIVM to create flexion flexion
lock from below

✓ Perform bilat extension PPIVM to create

extension lock from below

extension
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 Choice of lock should take into account:

✓ patient comfort (ex: presence of stenosis, disc issues, etc)

✓ hypermobile joints (cannot lock in direction of
Locking hypermobility)
✓ instability (cannot lock through an instability)
✓ direction of treatment technique (if treating twds flexion,
preferable to induce flexion/contra SF lock)

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Locking: Examples
→ You want to perform a unilateral flexion PPIVM on the right L3-4, patient has no special
considerations regarding locking

1) pt in L SL
2) perform flexion/contra SF lock up to L2-3, keeping L3-4 in neutral
3) perform bilateral flexion lock up to L4-5, keeping L3-4 in neutral
4) perform R unilateral flexion PPIVM L3-4

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Locking: Examples
→ You want to perform a unilateral flexion PPIVM at the R L5-S1. Patient has a R disc bulge at
L4-5. How would you lock?

→ You want to perform a bilateral flexion PPIVM at L4-5. Patient has a flexion hypermobility at
T12-L1 . How would you lock?

→ You want to perform a unilateral extension PPIVM at the left L4-5. Patient has a L disc bulge
at L5-S1. How would you lock?

→ You want to perform a unilateral extension PPIVM at the left L2-3. Patient has an anterior
shear instability at L4-5. How would you lock?

→ You want to perform a specific traction at L4-5. How?

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PAGs (review)
❑ Cranial (Flexion)

❑ Can add:

- Bilateral flexion
- SF contra
- Unilateral flexion (flex/SF)

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PAGs (review)
❑ Caudal (Extension)

❑ Can add:

- Bilateral extension
- SF ipsi
- Unilateral extension (ext/SF)

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References
❑ Dutton M. Orthopaedic Examination, evaluation and intervention. 4th edition McGraw Hill. 2017
❑ Whitmore, S., Gladney, K. & Driver, A. (2008) The lower Quadrant: A workbook of Manual Therapy
Techniques, 2nd Edition. Whitmore Physiotherapy Consulting Inc. Canada.
❑ National Orthopaedic Division Clinical Manual; Lower Quadrant; January 2023 edition.

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