Month: January 2010

This excerpt is part 1 of 2 from the Lumbar Spine Case Study Teleseminar

that was held on January 27, 2010:

 

Jordan describes a two-year history of variable low back pain.
The symptoms started two years ago when he was hit from behind
into the boards in hockey, and he describes this as a hyperextension
injury.  He has re-aggravated the symptoms when playing sports
throughout the past two years.
 
Currently, he complains of an ache (P1, intensity 3/10) across
his lower back that is worse after activity (7/10) and also
describes feeling “really tight a little higher” in his
lower back.  There are some symptoms into the buttocks at times,
but doesn’t particularly complain of symptoms extending into the
legs.

Some Clinical Findings Included:

Lumbar Spine ROM:
Flex  had decreased segmental movement – flattened Lumbar Spine,
Ext is limited to neutral with sharp pain reported lower lumbar region,
LSB caused a pulling pain on right side,RSB was no problem,
RRot produced sharp pain over right lower lumbar region,
LRot felt very tight over the right lower back.

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Lumbar Spine Passive Mobility Tests:
Decreased flexion L5/S1 right Z-joint with stretch type pain reported
Decreased extension L3/4, L4/5 right Z-joint

Lumbar Spine Stability Tests:
Pain with muscle splinting anterior & right torsional translation of L5

Based on his clinical findings it was determined that the patient’s
symptoms are a result of instability at the L5/S1 joint. 

His symptoms are consistent with spondylolysis. 
The young athlete with a pars interarticularis defect will
typically present with complaints of an ache in the lower back
that increase with activity.  There may or may not be a distinct
mechanism of injury but the athlete will often describe an
increase in pain with activities involving lumbar spine extension
and/or rotation.  The symptoms are typically localized to the
lumbar region with radicular symptoms seldom experienced. 

There may also be pain with active or resisted hip flexion
which produces anterior shear to the vertebra.

In part 2, I will demonstrate appropriate manual therapy
treatment techniques.

To Your Manual Therapy Success.

A client presents with restricted left neck rotation…

The detailed biomechanical exam reveals an articular restriction at the left Atlanto-Axial joint with no other significant findings.  They have been cleared from any upper cervical instabilities and vertebral artery compromise.

Assuming this is simply an articular restriction of C1-2…

…how would I determine the side of restriction? 

and…

…what is my manual therapy technique of choice to restore left rotation?

 To answer the first question…

I could use a manual therapy assessment format whereby I evaluate the PAIVMs (Passive Accessory Inter-Vertebral Movements) of C1 (Atlas) moving on C2(Axis), at the facet joints.  I would manually check the anterior and posterior accessory glides (with a slight bias towards inferior glide as well for both) of C1 moving on C2 at the facet joints.  This would be compared from left to right to determine which side is not moving well or is restricted.  With a left rotation restriction in this case, I would expect either to find a restricted posterior (with slight inferior) glide of the left C1-2 facet joint OR a restricted anterior (with slight inferior) glide of the right C1-2 facet joint. 
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You may be wondering why the slight inferior glide that is incorporated…this is because the shape of the Atlanto-Axial articular surfaces are slight biconvex due to the articular cartilage and this gives rise to a slightly inferior component of the glide.

Here is my answer for the second question…

Assuming that in this case (restricted left neck rotation), it was the left side of C1 not gliding posterior and slightly inferior on C2.  My preferred choice of a manual therapy technique to restore the mobility problem would be a Unilateral Traction of the left C1 on C2.  Below is a picture of this technique….

Unialteral Traction of Left C1 on C2:

 

To learn more about the details of assessing and treating Craniovertebral Region Joint Restrictions please email me at michael@manualtherapymentor.com  to sign up for the upcoming 1 DAY Workshop on the  January 17, 2010 located in the City of Vaughan.

PLEASE COMMMENT AND SHARE WITH FELLOW COLLEAGUES.