Biomechanical

Examination & Treatment

for the Lumbar Spine
Biomechanical Aspects of Clinical Reasoning

Steve Schneider, PT, MSPT, CMPT

Objectives

• To Discuss & Illustrate A Biomechanical Examination

Approach To Lumbar Assessment.
• To Discuss Integrating A Biomechanical Approach Into A
Comprehensive Examination And Into Multimodal
Treatments.
• To Discuss & Illustrate Various Manual Therapy
Techniques Commonly Used To Treat Lumbar
Dysfunctions (Lab: Slides 70+ on shared drive).
• (Regional Interdependence: Thoracic and SI Joint Exam
& Treatment Future Presentations ?)
Differential Diagnosis Exam

Material NOT Included In Lab Presentation

• Subjective Exam
• Medical History
• Medical Screening & Constitutional Symptoms
• Red Flags & Serious Pathology
• Yellow Flags
• Questionnaires: Functional Outcomes, Pain Scales,
Body Charts…
• Differential Diagnosis: Objective Tests
Differential Diagnosis Exam

• Inductive Evaluations: Judgments are withheld until a

relatively complete and thorough evaluation has been
completed.
• Deductive Evaluations: Therapist develops an early
hypothesis about the patient’s diagnosis, usually in the
presence of minimal information (don’t get biased by MD
diagnosis or Imaging).

• On Going Re-Assessments: Re-examine throughout care

is needed to confirm or refute your diagnosis hypothesis
and treatment plan.
Differential Diagnosis Exam

• Differential diagnosis is finding out if the patient is

appropriate for PT and “what” is wrong.

• Ongoing evaluations (biomechanical or other approaches)

should be looking for “why” it is happening & guide
treatment decision making.
Differential Diagnosis
Exam Findings
1. (+) Red Flags.
MD/surgical consult then treat if cleared.
2. Radicular symptoms or radiating pain that centralize
with traction (Especially Cervical Spine)
3. Radicular symptoms or radiating pain that centralize
with directional preference exercises
4. Mechanical LBP : Biomechanical hypomobilities
and/or instabilities contributing and/or causing pain.
(Biomechanical exam needed to confirm).
5. (+) Yellow Flags (Including Chronic Pain).
MD/ psychology consult if needed along with PT.
Non-Differential Diagnosis
Evaluations
1. Biomechanical Examination
2. Treatment Determined Exam:
McKenzie Classifications:
Postural, Dysfunction, Derangement.
3. Treatment Based Classification /
Clinical Predictor Rule Based Exam.
4. Other Approaches
Pillars of Evidence Based Practice

IDEAL
TREATMENT
 Grades of Evidence: JOSPT Lumbar
Clinical Practice Guideline (2012)
• Directional Preference/Centralization = A (Strong) Evidence
• Manual Therapy = A Evidence
• Stabilization: Trunk Coordination/ Strengthening = A
• Progressive Endurance/Fitness Activities = A Evidence
• Patient Education = B (Moderate) Evidence
• Flexion Exercises = C (Weak) Evidence
• Lower Quarter Nerve Mobilization Procedures = C
• Traction = D (Conflicting) Evidence
• (E= Theoretical/Foundational Evidence)
• (F= Expert Opinion)
Multimodal PT with “A” Rated Lumbar
Treatments

(Traction: “D” rated)

Directional Preference/ Specific Exercise/ ROM (A)

Manual Therapy (A) Progressive

Fitness/Aerobics (A) +
Pain Edu (Phase II)
Stabilization (A)

Home Program (Gym Program/Phase III)

Multimodal PT

Multimodal PT = Comprehensive treatment.

• This is NOT a shot gun approach but is based on
exam findings & clinical reasoning.
• Clinicians don’t have to be hampered by the
constraints that researchers have placed on
them—more pragmatic in practice.
• Treatment combinations obscure the effect of the
individual interventions that make up multimodal
treatment (Slaven EJ et al).
Lumbar Multimodal PT

Manual Clinical Reasoning Based

Therapy on Exam Findings to
Determine the % of Each
Directional Stabilization: Treatment Type For a
Preference: Specific &/or
ROM/ General Given Patient.
Flexibility
Pain The % Typically Changes
Education & During the Course of
Graded
Exposure
Treatment.
Lumbar Multimodal PT

• Clinical Reasoning Based on Exam Findings to Determine the

% of Each Treatment Type For a Given Patient.
• % Typically Changes During the Course of Treatment.
Multimodal PT
• Manual Therapy should not be done as stand
alone treatments.
• Combine with appropriate exercises (ROM &/or
Stabilization/Strengthening).
• Combine with education including Pain
Neuroscience Education & Graded Exposure
concepts.
• Put the “Bio” back in Biopsychosocial Model.
Acute PT Treatment Goals
• Reduce Pain/Centralize Symptoms:
(Directional Preference/Manual Therapy)
• Restore Mobility:
(Manual Therapy/Range of Motion Exercises)
• Restore Function
(Stabilization/ Strengthening Exercises)
• Teach Self Management Strategies &
Self Confidence/Resiliency of the body.
(Graded Exposure, Pain Neuroscience.)
Manual Therapy Evidence

Evidence To Support Manual Therapy

Manual Therapy Defined
Manual Therapy = A CPT/Billable Treatment Code.
Manual Therapy = Any hands on treatment technique.
Manual Therapy = Advanced Clinical Reasoning
1. Examination determined need for and type of
treatment(s).
2. Manual therapy treatment(s) performed.
3. Re-examination to determine effectiveness of
treatment(s).
2012 JOSPT LBP
Clinical Practice Guidelines
Manual Therapy is an “A” Rated Treatment Intervention.
• Clinicians should consider utilizing thrust manipulative
procedures to reduce pain and disability in patients
with mobility deficits, acute low back, and back-
related buttock or thigh pain.
• Thrust manipulative and non-thrust mobilization
procedures can also be used to improve spine and
hip mobility and reduce pain and disability in patients
with subacute and chronic low back and back-related
lower extremity pain.
2012 JOSPT LBP
Clinical Practice Guidelines
• The lumbar manipulation CPR (5 predictors) and
modified lumbar manipulation CPR (2 predictors) was
included in 2012 JOSPT LBP clinical guidelines.
• There is evidence for the use of thrust manipulation in
patients who do not meet the lumbar manipulation
CPR, including chronic LBP, lateral stenosis, and
spinal stenosis.
Lumbar Manipulation CPR
1. *No symptoms distal to knee.
2. *Recent onset of symptoms (<16 days).
3. Low FABQW (<19).
ALL of the top 3 criteria are PROGNOSTIC
* (#1 and #2) 2 prognostic factor CPR is also used.
4. Hyomobility of lumbar spine: BIOMECHANICAL.
5. Hip IR >35 in at least one hip.
• Part of the TBC: Manipulation (NOT Manual Therapy).
• (+) 4/5: prevalence 23-59%.
Lumbar Manipulation CPR
Which prognostic factors for low back pain are generic predictors of
outcome across a range of recovery domains? PTJ. 2013; 93(1): 32-40.
Cook CE et al.
• Meeting the CPR was prognostic for all outcome
measures and should be considered a universal
prognostic predictor.
• Patients with a (+) CPR were 4.8 x more likely to
improve compared to patients with a (-) CPR and
have a rate of recovery of 75% or greater regardless
of treatment group.
• Patients received thrust or non-thrust intervention for
2 visits then care directed by PT for subsequent visits.
Manipulation CPR VS Mobilizations

No difference in outcomes in people with low back pain who met the clinical
predictor rule for lumbar spine manipulation when a pragmatic non-thrust
manipulation was used as the comparator. Physiotherapy Canada. 2014;
66(4): 359-366.
• All patients met the lumbar manipulation CPR
• If patients met the CPR they do equally well with
thrust manipulation or non-thrust mobilizations.
• Both groups had significant improvements in pain
reduction (NPRS) and functional gains (ODI).
2012 JOSPT LBP
Clinical Practice Guidelines
• Assessment of hypomobility, in the absence of contra-
indications, is sufficient to consider the use of thrust
manipulation as a component of comprehensive
treatment.
• Mobilizations and manipulations are more effective in
combination with active therapies as a component of
a comprehensive treatment plan--Multimodal PT.
• Interventions targeting the hip joint as part of a more
comprehensive treatment program for LBP patients
can be considered— Regional Interdependence.
Manipulation Evidence
Lumbar spine segmental mobility assessment: an examination of validity for
determining intervention strategies in patients with low back pain. Arch Phys
Med Rehabil. 2005; 86:1745-1752. Fritz JM et al.
• Patients who were assessed as having lumbar
hypomobility demonstrated more significant
improvements with thrust manipulation and stabilization
exercises (Multimodal PT) than with stabilization
exercises alone.
• 74% with hypomobility and received manipulation has
successful outcomes.
• 26% with hypermobility (or lack of hypomobility) and
received manipulation had successful outcomes.
Manipulation Evidence
Effectiveness of physical therapist administered spinal manipulation for the
treatment of low back pain: a systematic review of the literature. IJSPT. 2012;
7(6): 647-662. Kuczynski J K et al.
• 6 Randomized controlled trails included.
• There is evidence to support the use of spinal
manipulation by PTs in clinical practice.
• PT spinal manipulation appears to be a safe intervention
that improves clinical outcomes (pain & function) for
patients with LBP.
• All studies found positive effects favoring manipulation
(or manipulation and exercise combined) versus a
control group.
Manual Therapy Evidence
The relative effectiveness of segment specific level and non-specific level
spinal joint mobilization on pain and range of motion: results of a systematic
review and meta-analysis. JMMT. 2013. 21(1): 7-17. Slaven EJ et al.
• Joint mobilizations improved outcomes by 20% relative to
controls who did not receive mobilizations.
• When used for treatment there is good evidence to support
the combination of joint mobilization and exercise--
Multimodal PT.
• However, treatment combinations obscure the effect of the
individual interventions that make up that treatment—
research dilemma.
Manual Therapy Evidence
The efficacy of manual therapy and exercise for different stages of non-
specific low back pain: an update of systematic reviews. JMMT. 2014.
22(2): 59-74. Hidalgo B et al.
• There is moderate to strong evidence for the benefit
(pain relief, functional improvement, overall health
and quality of life) of manual therapy compared to
sham manual therapy for all stages of LBP (acute,
subacute, chronic).
• A variety of manual procedures combined or not with
other interventions, including exercise, may improve
patient management– Multimodal PT.
Manual Therapy Evidence
The efficacy of manual therapy and exercise for different stages of non-specific
low back pain: an update of systematic reviews. JMMT. 2014. 22(2): 59-74.
Hidalgo B et al.
• There is moderate evidence to support manual therapy
over usual medical care for pain, function, and overall
health and quality of life for all stages of non-specific LBP.
• There is moderate evidence to support manual therapy
combined with exercise (or back school) for pain, function,
and return to work– Multimodal PT.
• There is limited to no-difference in efficacy of manual
therapy combined with extension exercises compared to
extension exercises alone for pain.
Manipulations VS Mobilizations

Early use of thrust manipulation versus non-thrust manipulation: A randomized

clinical trial. Manual Therapy. 2013; 18(3): 191-198. Cook C et al.
• Non-thrust mobilizations and thrust manipulation are
equally effective in producing the same outcomes in
mechanical LBP patients.
• Both groups had significant improvements in pain
reduction (NPRS) and functional improvements (ODI).
• Pragmatic design used: highly skilled PTs were allowed
to use mobilizations and manipulation as done in clinical
practice according to the patient’s presentation
(segmentally).
Manual Therapy VS Exercise
A perspective for considering the risks and benefits of spinal mainpulation in
patients with low back pain. Manual Therapy. 2006; 11(4): 316-320. Childs et al.
• Manipulation group at 4 weeks:
97% better; 3% no better or worse.
• Exercise group at 4 weeks:
89% better; 11% no better or worse.
• Exercise group 8x more likely to experience a worsening
in disability.
• Manipulation group also did exercises --Multimodal PT.
• Risk of not manipulating: 5-10% more “failed” patients
with exercise approach alone.
Manual Therapy Key Points
1. Manual therapy (manipulations & mobilizations) is
effective for treating all stages of LBP (Acute,
Subacute, Chronic).
2. Treatment effects include: reduced pain, improved
motion, improved function, improved neurodynamics
(SLR), and increase water diffusion into the nucleus
of the intervertebral disc.
3. The lumbar manipulation CPR can be used as a
guideline to assist with clinical reasoning –not a hard
fast “rule”.
Manual Therapy Key Points
4. Segmental manipulation of a hypomobile segment in the
absence of contra-indications is appropriate & effective.
5. Segmental vs gross manual therapy (manipulations &
mobilizations) of the lumbar spine are both effective.
6. Thrust manipulation vs non-thrust mobilization are equally
effective—but one might be more beneficial than the other
for a individual patient (get proficient at both).
7. Manual therapy & exercise are both effective for treating
LBP but both are better when combined— Multimodal PT.
Physical Therapy Effects

Manual Therapy/Physical Therapy Effects

• Biomechanical Effects.
• Neurophysiological Effects.
• Desensitization of Hypersensitive Tissues.
• Placebo/Nocebo Effects.
(Don’t be a Nocebo!)
• Therapeutic Alliance (Patient Beliefs Matter!)
Neurophysiological Effects
Immediate effects of regional-specific and non-regional specific spinal
manipulative therapy in patients with chronic low back pain: a randomized
controlled trial. PTJ. 2013; 93(6):748-756. de Oliveira RF et al.
• The immediate changes in pain intensity and pressure
pain threshold after a single high-velocity manipulation do
not differ by region-specific (painful lumbar area) versus
non-regional specific (upper thoracic spine) manipulation
techniques in patients with chronic LBP.
• Short-term/transient neurophysiological effects are the
same.
• (Is that the goal of the treatment?)
• (Why manipulate the painful level/potential instability?)
Manual Therapy Effects
Manual Therapy:
• Thorough Evaluation and ongoing Re-evaluations.
+ Healing Hands/ Manual Therapy Techniques.
+ Healing Words/ Appropriate Education.
+ Appropriate Therapeutic Exercise/ Home Exercises.
= Ritual between PT and patient with the formation of a
Therapeutic Alliance.
Abraham Verghese, MD: A Doctor’s Touch.
Link to Youtube video of TED TALKS (approx 20 min).
Biomechanical
Exam Findings
Finding Hypomobilities
Biomechanical Clinical Reasoning
Biomechanical Evaluation

1. Passive Physiological Inter-Vertebral

Movements (PPIVM) or Passive Physiological
Movements (PPM) in peripheral joints.
2. Passive Accessory Inter-Vertebral Movements
(PAIVM) or Passive Accessory Movements
(PAM) in peripheral joints: GLIDES.
3. Posterior to Anterior Pressures (CPAs/UPAs).
4. Secondary Stress Test (Segmental or Joint
Stability Tests).
Intervertebral Motion Testing

2012 JOSPT LBP Clinical Practice Guidelines

• Assessment of hypomobility, in the absence of contra-
indications, is sufficient to consider the use of thrust
manipulation as a component of comprehensive
treatment.

• Taken From:
Lumbar spine segmental mobility assessment: an examination of validity
for determining intervention strategies in patients with low back pain. Arch
Phys Med Rehabil. 2005; 86:1745-1752. Fritz JM et al.
Intervertebral Motion Testing

Finding Hypomobilities helps improve outcomes:

• Patients who were assessed as having lumbar
hypomobility demonstrated more significant
improvements with thrust manipulation and stabilization
exercises. (Fritz JM et al 2005).

• Risk of not manipulating: 5-10% more “failed” patients

with exercise approach alone. (Childs et al 2006)
 Intervertebral Motion Testing

2012 JOSPT LBP Clinical Practice Guidelines

• Segmental mobility testing: Prone PA’s & Side lying PPIVM.
• Reliability for presence of any hypomobility or hypermobility
during intervertebral motion testing demonstrated moderate
to good agreement.
• Kappa = 0.38-0.48.
• Validity has been established with correlation of radiographic
lumbar segmental instability and with response to treatment.
• PA’s for pain provocation: moderate to good agreement.
• Kappa = 0.25-0.55.
 Intervertebral Motion Testing
Intertester reliability and validity of motion assessment during lumbar spine
accessory motion testing. Phys Ther 2008. 88(1): 43-9. Landel R et al.
• The inter-tester reliability for identifying the least mobile
segment using posterior to anterior pressures (PA’s) was
good (agreement =82.8%; kappa= 0.71; 95% CI= 0.48-0.94).
• The inter-tester reliability was poor for identifying the most
mobile segment (kappa= 0.04; 95% CI= 0.13-0.71) despite
having good agreement (79.3%).
• PA’s had poor agreement versus MRI measured
intervertebral motion (Least mobile segment: kappa= 0.04;
95% CI =0.16-0.24 and Most mobile segment: kappa= 0.00;
95% CI=0.09-0.08)
Intervertebral Motion Testing
Spinal Motion Palpation: A Review of Reliability Studies. JMMT. 2002;
10(1): 24-39. Huijbregts, PA et al. (2 slides)
• Intrarater reliability is higher than interrater reliability.
• Intrarater reliability varies from less than chance to
substantial agreement depending on the study (and
palpation skill level).
• Interrater reliability only rarely exceeds poor to fair
agreement.
• Presence of Pain during motion testing had a higher
reliability than perceived motion.
Intervertebral Motion Testing
Spinal Motion Palpation: A Review of Reliability Studies. JMMT. 2002;
10(1): 24-39. Huijbregts, PA et al. (2 slides)
• PT’s without advance manual therapy training have been
shown to have poor interrater reliability in correctly
locating specific spinal levels.
• PT’s with advanced manual therapy training have good
interrater reliability in locating specific spinal levels.
• Interrater reliability impacted if cannot locate spinal levels.
• Clinically, it is more important to identify the presence of a
motion abnormality (& treat it) than to identify the spinal
level.
Intervertebral Motion Testing
The science of spinal motion palpation: a review and update with
implications for assessment and intervention. JMMT. 2013. 21(3): 160-67.
Nyberg RE et al. (2 slides)
• The decision to utilize manipulation for the purpose of
improving spinal mobility, or a motor control exercise
approach to provide spinal stabilization, may be
determined at least in part from an accurate
interpretation of spinal motion by palpation.
• The accuracy in interpreting spinal segmental motion
by palpation is, therefore, likely to affect treatment
outcome.
Intervertebral Motion Testing
The science of spinal motion palpation: a review and update with implications for
assessment and intervention. JMMT. 2013. 21(3): 160-67. Nyberg RE et al. (2)
Clinical considerations to improve accuracy and reliability:
• Use one or both of 1st two finger tips.
• Light force is better than strong forces.
• Slow motions are better than fast motions.
• Touch sensors (vs pressure sensors) are better at feeling
motion.
• Visually watch what you are doing to enhance accuracy.
• Use visual imagery.
• Practice frequently & Don’t over-analyze.
Intervertebral Motion Testing
Other clinical considerations to improve accuracy & reliability:
Use multiple techniques to confirm/validate your finding.
Use a cluster of 3-5 tests (like a CPR)—NOT JUST PAs.
1. PPIVM.
2. PAIVM: overpressure with endfeel.
3. PA’s (somewhat non-specific but used in most studies)
4. Segmental stability tests (&/or prone instability test)
5. Patient report of irritability/stiffness during testing.
6. A/PROM and combined movement testing.
7. Subjective history presentation.
Biomechanical Exam Results

• If PPIVM or PPM Tests are positive (+),

then a hypomobility is present

• If PAIVM or PAM Tests are also positive (+), then an

Articular Hypomobility exists

• If pain with glide then Acute or Subacute lesion

• If no pain with glide then Chronic Lesion
• PA’s would also be (+) for hypomobility
Types of Articular Hypomobilities
Articular Hypomobility
1. Facet Fixation (subluxation/pathomechanical dysfunction).
a) Facet Fixation In Flexion (Flexion Fixation):
cannot ext, SB left OR right
b) Facet Fixation In Extension (Extension Fixation):
cannot flex, SB left OR right.
2. Pericapsular Hypomobility:
Capsular pattern of loss (extension loss >> flexion loss).
3. Ankylosis/Fusion:
Fibrous Contracture, Bony Ankylosis, or Surgical Fusion
Types of Articular Hypomobilities

1. Fixated Joint (Subluxation):

Pathomechanical endfeel /Jammed.
Non-capsular pattern of motion loss
PPIVM/PPM/PAIVM/PAM:
(+) away from fixated position
(-) toward fixated position

Best Suited For Manipulation Treatment or

Erratic Grade 3+/4+ Joint Mobilizations When Appropriate
Types of Articular Hypomobilities

2. Pericapsular Hypomobility
Hard Capsular or spasm endfeel
Capsular pattern (usually)
PPIVM/PPM/PAIVM/PAM:
(+) in capsular pattern of loss of motion

Best Suited for Non-Manipulation Treatments:

Graded Joint Mobilizations,
Mobilizations with Movement, etc
Capsular Pattern of Spine

• Cervical Spine (C2-T1): Side Bending loss = Rotation loss

• Thoracic and Lumbar Spine: Ext Loss >> Flex Loss

Bilateral extension, side bending and rotation loss
much greater than flexion loss of motion.
• Unilateral Thoracic or Lumbar Facet:
Extension, ipsilateral side bending, and either
contralateral or ipsilateral rotation loss
much greater than flexion loss off motion.
Biomechanical Exam Results

• If PPIVM or PPM tests are positive (+),

then a hypomobility is present

• If PAIVM or PAM tests are negative (-),

then an Extra-Articular/Myofascial Hypomobility exists

• PA’s would be (-) for hypomobility

Types of Extra-articular
Hypomobilities

1. Muscle, tendon, myofascial

2. Contractures, scars
3. Hypertonus

• All will have elastic (not hard) end feel

• All will have a non-capsular pattern of loss of ROM
• Best Suited for Muscle Assisted Mobilizations (MAM),
Muscle Energy Techniques (MET), Soft Tissue
Mobilizations (STM), etc
Biomechanical Diagnosis

1. Articular Hypomobility
Fixated, Pericapsular, Fused
2. Extra-Articular Hypomobility
3. Joint Hypermobility
4. Joint Instability
Biomechanical Manipulation “CPR”

Biomechanical Manipulation “CPR”:

Presense of a Articular Fixation Hypomobility:
(+) History
(+) Scanning Exam: A/PROM, quadrant tests (H&I), &
PAs: hypomobile.
(+) Biomechanical exam: PPIVM, PAIVM, & PAs with a
hard / pathomechanical end feel.
AND (-) contra-indications for manual therapy.
Biomechanical Manual Therapy “CPR”

Biomechanical Manual Therapy “CPR” (Not Manipulation):

Presence of a Articular Capsular Hypomobility OR
Presence of an Extra-Articular Hypomobility:
(+) History
(+) Scanning Exam: A/PROM, quadrant tests, & PAs:
hypomobile +/- capsular pattern of loss of motion.
(+) Biomechanical exam: PPIVM, (+/ -) PAIVM, & (+/-) PAs
with a capsular end feel OR a soft/myofascial end feel.
AND (-) contra-indications for manual therapy.
Hypomobility Treatment

Graded Joint Mobilizations

• Grade 1-4: stimulate mechanoceptors (type II
primarily—possible type I) & have neurophysiological
pain modulation as oscillations preclude
mechanoreceptors from shutting down as they
accommodate the stimulus (gate control theory) plus
descending pathway inhibition (dPAG/mid-brain).
• Grade 1-2: Neurophysiological pain modulation
• Grade 3-5: Neurophysiological effect plus
biomechanical effect on the barrier to movement.
 Hypomobility Treatment
Graded Joint Mobilizations
Grade 1: Small Amplitude, rhythmic oscillations performed at the
beginning of ROM. Used to treat pain and spasm.
Grade 2: Large Amplitude, rhythmic oscillations performed within
available ROM (before barrier). Used to treat pain and spasm.
Grade 3: Large Amplitude oscillations performed up to end ROM.
Used to treat pericapsular hypomobility. Grade 3+ into resistance.
Grade 4: Small Amplitude oscillations performed at end ROM. Used to
treat pericapsular hypomobility. Grade 4+ into resistance.
Grade 5: Small Amplitude, high velocity at end ROM / manipulation /
thrust. Used to treat pathomechanical /subluxed /fixated joints.
Erratic grade 3+ mobilizations may also be effective.
Hypomobility Treatment
Mobilization With Movement (MWM):
• No pain should be experienced with MWM techniques.
• Joint mobilizations should be parallel or perpendicular to
joint surface—MWM are primarily parallel mobilizations
(NAGS).
• MWM are sustained throughout movement (SNAGS).
• Bony positional faults contribute to painful joint restrictions.
• Minor bony positional faults are not palpable or visible on
X-ray.
• MWM repositions joint so it can move pain-free (10 reps).
Hypomobility Treatment

Active Mobilizations:
• Muscle Energy Techniques (MET)
• Muscle Assisted Mobilizations (MAM)
• Positional Isometric Techniques (PIT)
• Used to treat Myofascial/ Extra-Articular
Hypomobilities
• Useful as a preparation technique prior to
mobilizations or manipulations.
• Useful as initial post mobilization or manipulation
neuromuscular re-education technique.
Hypomobility Treatment
Soft Tissue Mobilizations (STM):
• Tool / Instrument Assisted STM (TASTM) / (IASTM)
• Cross Friction STM
• Trigger Point STM
• Visceral Mobilization
• Myofascial Release/Massage
• Myofascial Decompression (MFD) / Cupping
• Massage Gun (Recover Fun, Hypervolt etc)
Dry Needling:
NOT INCLUDED IN JOSPT LBP CLINICAL GUIDELINES
Hypomobility Treatment

Dural Mobilizations: Tensioners and Sliders.

• May be considered Therapeutic exercise or
Neuromuscular Re-education versus Manual Therapy.

• Lower Quarter Nerve Mobilization Procedures = C

(Weak) Evidence in the JOSPT LBP Clinical Guidelines.
Functional &
Clinical Instability
Finding Instabilities
Intervertebral Motion Testing
Accuracy of the clinical examination to predict radiographic instability of the
lumbar spine. European Spine Journal. 2005; 14(8): 743-750. Fritz JM et al.
• A Central Poster-Anterior (CPA) test finding of “lack of
hypomobility” was the BEST individual test for diagnosing
lumbar instability.
• If a clinician had 50% certainty that a patient had lumbar
instability, then a “lack of hypomobility” based on CPA
testing would increase the probability of instability to 90%.
• Combining a finding of lumbar flexion AROM of >53
degrees with a CPA test finding of a “lack of hypomobility”
increased the likelihood of instability from 50% to 93%.
Biomechanical Exam Results

• If PPIVM or PPM Tests are negative (-),

then joint movement is normal OR if felt to be excessive a
joint instability or hypermobility is present.
• PAIVM or PAM would be also be (-) so normal or excessive
joint movement present which is difficult to assess
(so a lack of hypomobility may be adequate).
• PA’s would be (-) for hypomobility but may be (+) for pain
or muscle hypertonicity (might have pain with PAIVM too).
• Secondary Stress Tests (segmental or joint stability test) can
help ID instability (which is often difficult to assess).
Functional Instability Exam Findings

History Findings:
• Episodic LBP
Often progressively worsening. But may be first episode.
• Subjective Crepitus, Clunk, or “Giving Away” with Bending or
Twisting.
• Greater Pain Returning From Flexion, Than With Flexion.
• Difficulty Changing Positions (Catching, Locking, Pain):
Rolling in bed, supine to sit, sit to stand, etc.
• Discomfort Or Pain With Unsupported Sitting Or Sustained
Positions.
• Increase Pain With Sudden or Mild Movements.
• Prior good but short term relief with manipulation.
• Frequently Feeling Need to “Crack or Pop” Back.
• Relief with immobilization—bracing.
Clinical Instability Exam Findings
Differential Diagnosis / Scanning Examination Findings:
(+) Aberrant Spinal Motion with AROM Testing:
Gower’s Sign: walking up thighs. Painful arc. Instability catch.
Reversal of lumbopelvic rhythm. Deviation from sagittal plane.
(+) Excessive ROM and /or Pain at End Normal ROM.
(+) H & I Tests: Combined Movement/Quadrant Tests.
(+) Objective Crepitus or Clunk With ROM or Other Tests.
(+) Prone PA Pressures: Provocative not Hypomobile.
(+) Prone Instability Test (PA + PA with extensor contraction).
(+) Secondary Stress Test (Sidelying Anterior Shear)
(+/-) Primary (General) Stress Tests:
Traction, Compression, Torsion.
(+/-) Directional Preference or Centralization:
Often instability pain with sustained positions.
Biomechanical Clinical
Instability “CPR”
Presences of a Clinical Instability:
(+) History
(+) Differential Diagnosis Exam:
Excessive ROM / Hypermobility: A/PROM,
Quadrant Tests (H & I), PAs, Prone Instability Test.
(+) Biomechanical Exam: Hypermobility (lack of hypomobility):
PPIVM, PAIVM, PA & empty/ pain/ spasm end feel.
(+) Secondary (Segmental) Stress Tests (S/L Anterior Shear)
• Lumbar, Thoracic, Sacroiliac Joint, & Hip Assessed.
Hypomobilities often found in adjacent structures.
“LAB”: Objective
Examination
A/PROM Testing (Part of Diff Dx Exam)
Lateral Shift Examination
Lateral Shift Correction Exercises
Active Range of Motion Testing
• Range of Motion: Degree or Percentage.
• Patient’s Willingness to Move
• Pattern of Restriction
• Quality of Movement
• Presence of Aberrant Motion
• Onset and Type of Symptoms (kappa 0.51-o.76)
• Presence of Centralization/Directional Preference
• Typically the Cardinal Planes of Motion are Tested
• Combined Movements/Quadrant Tests are done if
Full or Near Full ROM is Present.
AROM: Extension & Flexion
Presence of Aberrant Movement

Includes the presence of any of the following:

• Painful arc with flexion or return from flexion

• Instability catch

• Gower Sign = Thigh climb

• Reversal of lumbopelvic rhythm

Directional Preference Therapy

• Clinician judges the behavior of symptoms in

response to movement testing to assess
whether centralization or peripheralization of
symptoms occurs.
• The patient is asked to flex and extend in the
sagital plane (or laterally shift the pelvis in
the frontal plane) in standing,
supine/quadruped, and prone with single and
repeated movements in a systematic fashion.
Extension Preference Exam
Flexion Preference Exam
Extension & Flexion Preference
AROM: Side Bending & Rotation
Passive Range of Motion Testing
• Passive assessment of the integrity of inert tissues:
capsule, ligaments, bone, bursa, fascia, dura / nerve
• Test for:
 Amount of PROM: Degree or Percent.
 Range Differences Between Passive & Active Tests
 Patient willingness to move/anxiety with
movements.
 End feel.
 Quality of Motion.
 Aberrant Movement patterns: Mode of Recovery
from End-Position.
 Symptoms Produced (type and location)
PROM with Overpressure:
Extension & Flexion
PROM with Overpressure:
Side Bending & Rotation
Combined Movement/Quadrant Testing

• Tests both the ROM and function of the joint complex.

• Best used in subacute or chronic stages of healing.
• Can assist in detecting hypomobilities,
hypermobilities, and instabilities.
• If planar motions fail to reproduce symptoms and
AROM is full or near full, then combined motions can
be introduced.
• Combined Motion: Typically Diagonal Patterns.
 H TEST:
(More sensitive detecting lateral instabilities)
 I TEST:
(More sensitive detecting A/P instabilities)
H & I: Quadrant Testing
Seated SLR & SLUMP Tests
Straight Leg Raise (SLR)
Prone Knee Bend Test
Objective Examination
Lumbar Primary Stress Tests
NOT INCLUDED
Objective Examination
Palpation & Peripheral Joint Screening
NOT INCLUDED
Objective Examination
Stabilization Strength Testing
NOT INCLUDED
Biomechanical
Examination
PPIVM’s, PAIVM’s, and PA’s
* Sign
• Key objective sign that warrants manual therapy treatment.
• Segmental joint hypomobility (PA, PPIVM, PAIVM).
• Hypertonicity/ myofascial restriction.
• PROM restriction.
• AROM and combined motion restriction.
• Can have subjective input like “Comparable sign” for finding
painful hypermobilities/instabilities (Grade 1-2 treatments) or
assist with finding hypomobilities (Grade 1-5 treatments).
• After treatment, this key objective finding is retested to
confirm treatment effect or lack of effect.
Biomechanical Evaluation

1. Passive Physiological Inter-Vertebral

Movements (PPIVM) or Passive Physiological
Movements (PPM) in peripheral joints.
2. Passive Accessory Inter-Vertebral Movements
(PAIVM) or Passive Accessory Movements
(PAM) in peripheral joints: GLIDES.
3. Posterior to Anterior Pressures (CPA/UPAs).
4. Secondary Stress Test (Segmental or Joint
Stability Tests).
Lumbar PPIVM/PAIVM

Passive Physiological Intervertebral (Segmental) Motion &

Passive Accessory Intervertebral (Segmental) Motion:
GLIDES.
• Flexion
• Extension
• Right/Left Side Bending
• Right/Left Rotation
• Combined Movements

Step Test: Positional Test

Lumbar Flexion PPIVM/PAIVM

• The pt is positioned in side lying facing the PT. They are

asked to slide close to the edge of the table—the PT can
place their fist close to the edge of the table to mark
where the patient should lie.
• PT’s cranial arm hooks under the pt’s top arm & the PT’s
hand palpates for segmental motion.
• PT’s caudal arm holds the pt’s legs against the PT’s
thighs. Flexion motion is introduced by the PT’s arms &
body.
• Overpressure (PAIVM) can be done with caudal hand
while stabilizing the top segment with the cranial hand.
Lumbar Flexion PPIVM/PAIVM
Lumbar Extension PPIVM/PAIVM

• The pt is positioned in side lying facing the PT. They are

asked to slide close to the edge of the table. The pt
moves their shoulder back toward the center of the
table to bias extension.
• PT’s cranial arm hooks under the pt’s top arm & the PT’s
hand palpates for segmental motion.
• PT’s caudal arm holds the pt’s legs against the PT’s
thighs with the pt’s knees flexed. Extension motion is
introduced by the PT’s arms & body.
• Overpressure (PAIVM) can be done with caudal hand
while stabilizing the top segment with the cranial hand.
Lumbar Extension PPIVM/PAIVM
Lumbar Side Bending PPIVM/PAIVM

• The pt is positioned in side lying facing the PT. They are

asked to slide close to the edge of the table.
• PT’s cranial arm hooks under the pt’s top arm & the PT’s
hand palpates for segmental motion.
• PT’s caudal arm holds the pt’s pelvis against the PT’s
body. Side bending motion is introduced by the PT’s
arms & body.
• Overpressure (PAIVM) can be done with cranial hand
while stabilizing the lower segments through the pelvis.
• Side bending can be done ipsilaterally (L SB if in R S/L) or
contralaterally (R SB if in R S/L).
Lumbar Side Bending PPIVM/PAIVM

Right SB Left SB
Lumbar Side Bending
PPIVM/PAIVM: Alternative
• The pt is positioned in side lying facing the PT. They are
asked to slide close to the edge of the table.
• PT’s cranial arm hooks under the pt’s top arm & the PT’s
hand palpates for segmental motion.
• PT’s caudal hand holds the pt’s legs above the ankles with
the pt’s legs against the PT’s thighs. Side bending motion
is introduced by the PT’s arms & body by raising or
lowering the patients distal legs. Can do ipsi- &
contralateral SB.
• Overpressure (PAIVM) can be done with cranial hand while
stabilizing the bottom segments through the pelvis.
Lumbar Side Bending
PPIVM/PAIVM: Alternative

Right SB Left SB
Lumbar Rotation PPIVM/PAIVM

• The pt is positioned in side lying facing the PT. They are

asked to slide close to the edge of the table.
• PT’s cranial arm hooks under the pt’s top arm & the PT’s
hand palpates for segmental motion.
• PT’s caudal arm stabilizes the pt’s pelvis against the PT’s
body & the caudal hand palpates for motion of the inferior
segment.
• Rotation motion is introduced by the PT’s cranial arm &
body.
• Overpressure (PAIVM) can be done with cranial hand while
stabilizing the bottom segment with the caudal hand.
Lumbar Rotation PPIVM/PAIVM
Lumbar Combined Motion
PPIVM/PAIVM

Flexion, SB, Rot Extension, SB, Rot

Lumbar/Thoracic Step Test

Positional Test:
• The patient is positioned in side lying facing the PT. The
patient’s top side is being tested.
• The PT positions the patient in flexion, rotation, and
(contra-lateral) side bending and/or extension, rotation, and
(ipsi-lateral) side bending combined motion positions.
• The lower thoracic and lumbar spine is visually inspected
and palpated for deviation from a gradual, even curve from
pelvis to the treatment table (like a spiral stair case).
• (+) = deviation from a gradual, even curve.
Lumbar/Thoracic Step Test

Flexion Bias Extension Bias

Posterior to Anterior (PA) Pressures

• Primary Stress Test : Pain Provocation with Segmental PA

Testing: PA pressure is applied at each spinal level and pain
provocation is judged as present or absent (Spring Tests can
be done multi-segmentally).
• Segmental Mobility Test: PA pressure is applied to each spinal
segment movement. Movement judged as normal,
hypomobile, or hypermobile (lack of hypomobility).
• Maitland/Cook use Central PAs and Unilateral PAs along with
patient’s feedback (Comparable/* Sign) vs end feel.
• Passive Physiological Intervertebral Motion (PPIVM) Tests and
Passive Accessory Intervertebral Motion (PAIVM) Tests are
part of the biomechanical examination and are used for
clarification/validation of abnormal PA motion findings.
• Even though PA’s are done segmentally, they are considered
a primary/general stress test.
Posterior to Anterior Pressures:
Central PA’s (CPA’s)
Posterior to Anterior Pressures:
Unilateral PA’s (UPA’s)
Positional Testing

• Ostopathic (Michigan State) Approach: Muscle Energy.

• Extended, Rotated, and Side bent (ERS) and Flexed,
Rotated and Side bent (FRS) biomechanical diagnosis
based on visual inspection and palpation of individual
vertebra in neutral, flexion, and extension.
• Potentially less reliable than segmental motion testing.
• Anomalies & asymmetries are common / “normal”.
• Have not seen research on this nor is it included in the
JOSPT LBP clinical guidelines.
• Can be a helpful clinical tool for some clinicians.
Positional Testing

• Positional testing done in neutral, flexion, & extension

to give a positional diagnosis: flexed, side bent, &
rotated (FRS) or extended, side bent, & rotated
(ERS).
• Can have (+) positional findings for hypomobility,
hypermobility, anomaly, or compensatory scoliosis.
• Therefore, not specific for biomechanical movement
dysfunction – can be combined with motion testing.
• Additional testing needed to confirm hypomobility
versus other potential (+) findings.
Biomechanical
Examination
Lumbar Secondary Stress Tests
Prone Instability Test &
Modified Prone Instability Test
Prone Instability Test (More of a Primary Stress Test)
• Patient is prone with legs over edge of table and feet resting
on floor. PT applies PA force to lumbar spine (segmentally).
Any provocation of pain is noted.
• Patient lifts LE’s off floor and PA re-applied to lumbar spine
(segmentally).
• (+) if pain is present with PA in resting position but subsides in
the contracted position.
• Modified Pone Instability Test: Prone PA then prone PA with
LE’s lifted of table (better flow with examination process).
Prone Instability Test &
Modified Prone Instability Test
Segmental Stability Test:
Anterior Shear
Anterior Shear (Biomechanical exam: secondary/segmental test)
• Patient is in sidelying with hips flexed and lumbar neutral.
• An anterior shear force implemented by stabilizing the top
segment and pushing the patient’s bottom segment posteriorly
through the patient’s femurs.
• (+) = pain reproduction and/or therapist’s palpation of muscle
guarding or excessive segmental motion/glide (crepitus /
catching /clicking) .

• Can re-test with transversus abdominis contraction.

• Can re-test with posterior pelvic tilt.
Segmental Stability Test:
Anterior Shear with TrA
Anterior Shear with TrA activation (ADIM/Kegel)
• If anterior shear test is (+) retest that segment
with lumbar spine still in neutral and add
transversus abdominis (TrA) contraction
(ADIM/Kegel).

• If symptoms reduce then treat with stabilization

program.

• If still (+) then worse prognosis.

Segmental Stability Test:
Anterior Shear with PPT
Anterior Shear with posterior pelvic tilt (PPT)
• If prone instability test is (+) then retest that segment in
lumbar flexion to get stability from posterior ligaments and
fascia.
(Posterior Longitudinal Ligament/Supraspinous Ligaments etc).

• If symptoms reduce than better prognosis and can use

posterior pelvic tilt rehabilitation strategy.

• If still (+) then worse prognosis.

Segmental Stability Test:
Anterior Shear
Biomechanical
Examination
Other Secondary Stress Tests
NOT INCLUDED
Lumbar Treatment
Manual Therapy
Manual Therapy
Contra-Indications
1. Evidence that condition is not musculoskeletal:
Cancer, bone disease, infections process, septic or
traumatic arthritis, acute RA or AS
2. Evidence of serious trauma: fracture, dislocation,
rupture, bony or empty endfeel, adverse joint
environment (spasms)
3. Long term steroid use
4. Bleeding disorder/ on anticoagulants
5. Signs/symptoms of spinal cord involvement
6. Cauda Equina Signs/ Symptoms
Manual Therapy
Contra-Indications
7. Involvement of more than one spinal nerve root (C/T
spine) or >2 adjacent or 2 non-adjacent nerve roots
(L-spine).
8. 1st or 2nd lumbar root palsy
9. Sign of Buttock
10. Sign of Vertebro-Basilar Insufficiency (VBI)
11. C1/C2 Transverse ligament instability
12. Emotionally dependent patient.
Manual Therapy
with Caution
1. Rheumatoid Arthritis
2. Osteoporosis
3. Past History of Cancer
4. Systemic Steroid Therapy
5. Pregnancy
6. Presence of Neurological Signs:
Fatiguable weakness of key muscle (myotome),
Deep tendon reflex changes,
Dermatomal sensory changes, Pathological Reflexes—
NOT pain (referred or radiating pain not a neuro sign)
Manual Therapy
with Caution
7. Primary Posterolateral Disc Protrusion
8. Hypermobility / Instability
8. Spondylolisthesis
9. Acute Inflammation Signs/Symptoms
10. Dizziness
11. Cervical Trauma Onset of Symptoms
12. Chronic Pain Central (& Peripheral) Nervous System
Sensitization
General Manual Traction

Supine Lumbar Traction Via Leg Pull:

• Bilateral, Unilateral.
• Variable Angles (0-60), (70-90 From Pelvis) +/- Belt.

Prone Lumbar Traction Via Leg Pull:

• Bilateral, Unilateral.
• Variable Angles (0-30) +/- Belt.
Directional Preference

• Lateral Shift +/- Manual Therapy

• Extension Preference Exercises +/- Manual Therapy

Graded Mobilizations
Mobilizations with Movement

• Flexion Preference Exercises +/- Manual Therapy

Graded Mobilizations
Mobilizations with Movement
Lumbar Segmental Locking for Traction,
Mobilizations, & Manipulations

Locking from Above:

1. Neutral (not flexed or extended).
2. Flexion: SB/ipsilateral rotation & SB/contralateral rotation.
3. Extension: SB/ipsilateral rotation & SB/contralateral rotation.

Locking from Below:

1. Neutral (not flexed or extended).
2. Flexion: SB/ipsilateral rotation & SB/contralateral rotation.
3. Extension: SB/ipsilateral rotation & SB/contralateral rotation.

5 options from above & 5 from below = 25 positional options

Lumbar Mobilization Treatments

Traction: Neutral Lock From Side Lying Blanket Roll

Above and Below Semi-Specific Traction
Lumbar Mobilization Treatments

Extension: Extension Lock From Flexion: Flexion Lock From

Above and Below Above and Below
Lumbar Mobilization Treatments

• Posterior to Anterior Pressures (PA/CPA/UPA)

1. Reduce pain.
2. Improve motion-Extension
(non-physiological motion).
3. Improve disc hydration.

• Graded Joint Mobilization for Treatment.

• Mobilization with Movement:

Combined With Extension Exercise
Lumbar Mobilization Treatments

Central PA’s Unilateral PA’s

Lumbar Segmental Manipulations

Gapping: Neutral Lock From Above and Below

Lumbar Segmental Manipulations

Extension: Extension Lock Flexion: Flexion Lock From

From Above and Below Above and Below
Lumbar Non-specific Manipulation
Lumbar Treatment
Early Lumbar Stabilization Concepts
Stabilization Therapy

• Avoidance of excessive ROM by patient

• Posture and Body Mechanics Correction
• Reduce stress from adjacent joints : treat surrounding
hypomobilities including hips, thoracic and lumbar spine,
SI Joints—Biomechanical Exam & Manual Therapy.
• Anti-inflammatory modalities if necessary
• Bracing if necessary (Structural/Clinical Instability)
• Remove or decrease pain/reflex inhibition if necessary
with de-facillitation manual therapy techniques
• Stabilization Therapy/Exercises
Stabilization Therapy Sequencing

1. Pelvic Floor
2. Abdominal Muscles: Transversus Abdominis,
Internal/External Obliques, Rectus Abominis.
3. Multifidus.
4. Hip Stabilizers if needed: Glutes &
Hamstrings
5. Psoas if needed
6. Diaphragm if needed .
Specific Exercises Not Covered Today
Regional Interdependence:
Biomechanical Aspects of
Clinical Reasoning
Thoracic & SI Joint Exam & Treatment
Next Presentations
References
Evidence Based Practice
Research Component of
Evidence Based Practice
• American Physical Therapy Association (APTA):
Physical Therapy Journal (PTJ).
• Orthopedic Section of the APTA: Journal of Orthopaedic
and Sports Physical Therapy (JOSPT).
• 2012 JOSPT Low Back Pain Clinical Practice
Guidelines.
• American Academy of Orthopaedic Manual Physical
Therapist (AAOMPT): Journal of Manual & Manipulative
Therapy (JMMT).
• Links from AAOMPT, MAPS, NAIOMT, Physiopedia etc.
NAIOMT

 Level I: Bill Temes, PT, OCS, COMT, FAAOMPT.

 Level II A: Michele Roy, PT, MCPA, FCAMT.
Level II B: Michele Roy, PT, MCPA, FCAMT.
 Level III A: Jim Meadows, PT, MCPA, FCAMT.
 Level III B: Erl Pettman, PT, MCSP, MCPA, COMT.
 Level IV: Erl Pettman, PT, MCSP, MCPA, COMT.
NAIOMT

2010 NAIOMT Symposium:

• Functional Approach to Motor Control Rehabilitation
of the Lumbopelvic Complex. Kathy Berglund, PT.
• Hidden Link of Spondylolisthesis. Ken Cole, PT;
Mark Looper, PT; Laura Von Wullerstorff, PT.
• Thoracolumbar Syndrome. Kent Keyser, PT.
• The “Dynamic” Pelvis. Erl Pettman, PT.
NAIOMT
2015 NAIOMT Symposium: Sacroiliac Joint.
• Overview of Anatomy/Function: Earl Pettman, PT.
• SI Joint: Cliff Fowler, PT.
• The True Role of SI Joint in Lower Quadrant
Dysfunction: Ann Porter Hoke, PT.
• Odd Dysfunction Presentations in the SI joint:
Kent Kayser, PT.
• Is this SI joint pain?: Susan Clinton, PT
• SI joint pain in runners: Kathy Stupanski, PT.
Chad Cook: Medbridge

• Evidence Based Evaluation of Lumbar Spine

• Evidence Based Treatment of Lumbar Spine
• Evidence Based Evaluation of Thoracic Spine
• Evidence Based Treatment of Thoracic Spine

(Chad Cook is a Maitland/MAPS Trained PT)