PHTH 565 Manual Therapy Lecture Notes

ANDREA’S SECTION
NEURODYNAMICS FOR LOWER QUADRANT
Neural Mobility Theory = Nervous system as a continuum, responsible for conduction of afferent/efferent messages, free to move
as trunk/head/limbs move  movement allows for nutrition of nerve and for its target tissues
 Lumbar & sacral plexus = physical connection between spinal cord/column and LE
o Nerve roots need to move through IVF
o Spinal cord and cauda equina must move within spinal canal
o Peripheral nerves must move through other soft tissue interfaces

Dural Tension
 Increased distal motion/tension of peripheral nerve structures with knee extension and/or ankle DF
 Increased cranial motion/tension of cord w/ spinal or neck (esp. CV) flexion  bilateral motion in (proximally) through IVFs
 Areas of common dural tension (normal fixations) in everyone = C5, T6, L4
 Abnormal points (fixations) of dural tension = muscle scarring, osteophyte, locations where nerves branch
 Compressed nerve = very intolerant to more tension (tests become quite provocative)
Assessment
Subjective (Indicators of potential neurodynamic issue) Objective
-Weird descriptions of pain -Previous or persistent injury -Scan for safety = assess hard neurological (conduction signs)
-Increased repetition or speed of work or sport  DO NOT assess or treat neural mobility in presence of CNS SIGNS
-Lines of symptom distribution  may not relate to nerve root or  DO assess neural mobility carefully while peripheral nerve conduction signs are
peripheral nerve distribution present (care with slump i.e. spinal compression)
-Aggravated in positions of neural tension  DO NOT treat using neural mobility while peripheral nerve conduction signs are
-Multiple problems in same limb present
-Note irritability to determine approach for objective -Dermatomes, myotomes, reflexes, spinal reflexes, Lower/Upper quadrant scans

Is adverse neural mobility part of the problem?

Likely YES, if 1 or more of the following (best w/ all 3): Likely NO, if:
-Pt’s symptoms or something similar reproduced (+/- abnormal end feel) -Pt’s symptoms are not reproduced
-Range achieved < contralateral side or expected normal -Range and symptoms achieved are w/in normal limits  expected range,
-ROM or symptoms of test change w/ movement of remote areas  i.e. equal to contralateral side, sense of stretch or subtle paraesthesia
if neck movement changes leg pain or ROM or SLR or Slump, neural -ROM or symptoms do not change w/ movement of remote areas
mobility likely relevant -All tests seem to be positive (i.e. there are other obvious indicates of central
sensitization of pain)

Straight Leg Raise (SLR): L5, S1, S2 Assessment Findings

What’s happening in nervous system: 1)“During this test, tell me when and where you are feeling some NOTE: end feel, range, response to
-Nerve root moves out of ipsilateral IVF with pain” movement of associated areas
progressive hip flexion in SLR 2)Patient’s knee in full extension (flexion takes resistance off (compensatory)
-Contralateral nerve root gets pulled relatively in system), then flex hip keeping leg straight
through IVF 3)STOP at first sign of tissue resistance or if patient reports Positive = (1) Recreation of pt’s
-Some lateral shifting of spinal canal contents symptoms symptoms (best positive); (2) less
-First 30  taking up slack in system 4)THEN drop back a bit and add tension to system mobility on affected side; (3)
-Next 35-70  Increase distal motion/tension with sensitization maneuvers at differences in resistance felt on
sciatic nerve moves ankle via sciatic system = passive dorsiflexion either side (Stretch pain behind
caudally (nerve  Increase cranial motion/tension w/ neck flexion via cord = knee is normal) (4) empty/muscle
movement ends) active chin to chest  can recreate symptoms by pulling on spasm end feel
-Beyond 70  nervous system or decrease symptoms by moving nervous
adding tension in system off an area of tightness Crossed SLR findings can occur
system with disc injuries
Slump Test Assessment Findings
-Helps detect disc lesion or dural tethering 1)Pt seated w/ hands clasped together behind back -Normally some discomfort w/ test  look for
-Moves pain sensitive structures in vertebral canal 2)Pt slumps through full range of lumbar  thoracic differences between two sides
and IVF spine flexion -Note symptom response with each step 
-Performed during Lumbar Spine Scan, especially 3)Flex C-spine fully (hand on head holding)  note typical to feel tension in mid-thoracic region,
in patients having low back pain with or without symptoms and range posterior thigh and behind knee
leg symptoms (e.g. pain, paraesthesia) 4)Fully extend knee on unaffected side (actively or -Note reproduction of symptoms, ROM, and
-More sensitive than SLR as dura already pulled passively) end-feel at each stage
cranially (via spinal flexion portion of test), prior to 5)Fully dorsiflex the ankle on the unaffected side Do symptoms change with alterations in
adding lower extremity components 6)Extend C-spine  note relief symptoms and/or tension (e.g. letting pt extend neck back to
increased range of knee extension neutral, flex knee, or PF ankle)
Positive Findings: 6)Release and repeat (4) and (5) on the affected side.
-Reproduces pt’s symptoms, +/- abnormal *Add one component at a time AND slowly
resistance, +/-decreased ROM *Check in w/ pt at each stage, stop and check before
-Produces increased ‘normal response’ as progressing through steps
compared to other side

Contraindications to Neural Mobility Treatment

 Presence of hard neuro (conduction) signs
 Worsening symptoms
 Undiagnosed symptoms
 Severe irritability
 Latent pain (pain way worse ~12 hrs later)

Neural Mobility Treatment

 Treating adverse neuro dynamics = flossing, tension, or treating interface where lesion is
 Initial Treatment Recommendations:
o Determine irritability
o Err on side of caution
o Start with grade 2 slider = large amplitude, NOT into any resistance or reproduction of symptoms
o Start with movement of an area that is remote to symptoms,
o OR try ‘indirect’ treatment (interface, posture, etc.)
 Treatment Progression:
o Even if non-irritable, easy to flare people up = be careful!
o Go further into range or resistance  DON’T provoke pain, only a sense of moderate stretch
o Increase Reps
o Add movement through components closer to symptomatic area
o Incorporate additional sources of tension
o Treat interface, with/without neural tension (“rope through the closed door”)

Sliders Tensioners
-Can use SLUMP or SLR positioning -Can use SLUMP or SLR positioning
for exs for exs
"Kick your head off" > kick foot up -Tension it on then off then on then off;
(SL) and neck extension (up) go from nothing to alot with tiny
Min 10 reps, to as much as 3x10 movements; only want to feel tenson
reps as an intro volume per day; of 6/10, not 10/10
consider risk of latent pain and how
close to irritable
LOWER LEG/ANKLE/FOOT MANUAL THERAPY
 Information from squat test = location of pain, t/c wrinkles, splay or mortice, DF/compression test, strength, instability
 Observation = change in hair distribution, change in muscle bulk/shape, orientation of calcaneous, sway test (observe from
back), heel raises (strength, ROM, should see calcaneous inversion, progress to single leg), balancing

Inferior Tibiofibular Joint (IFT)

*Common mechanism of injury = full DF + external Rotation
Pain Provocation Dorsiflexion/compression test: looking for Squeeze test:
(For high ankle pain with DF/squat  Then add squeeze mid-calf to
sprain diagnosis, compression across maleoli and retest compress proximal tib
but less useful for squat looking for decreased pain or and fib together,
stability increase range looking for pain
assessment) reproduction at inferior
Palpation or “Point” test: palpate anterior tib-fib joint (?
aspect of IFT joint  Draw joint line between distraction at inferior
caudal aspects of malleoli, palpate 1/3 from tib-fib?)
lateral malleoli
Note: length of tenderness
Stability Testing Anterior/Posterior glide of fibula
*Generally, hold all -Glide fibula on stabilized tibia in crook lying
stability tests for 5- -Use whole thenar eminence along lateral aspect of fibula, stabilizing hand over medial
10s malleolus to stabilize tibia
*Looking for how -Normal end feel = ligamentous
far it goes + end
feel compared to ?Splay on squat
unaffected side -Wrap tape measure around ankle just inferior to malleoli
-Have pt squat down
-Gain >2mm = unstable mortice
External rotation test
-Patient is sitting with legs over edge of the plinth
-Stabilize proximal tibia and fibula, passively take relaxed (plantarflexed, can move into
easily attained DF) foot into external rotation
-Positive test = pain reproduced over ITF joint and/or increased ROM compared to
unaffected side
Talocrural Joint Stability Testing
General Talocrural Distraction
Stability -Fingers linked with 5th fingers over neck of talus
-Maintain enough DF to have purchase on talus and pull toward sole of foot
-Bring elbows in to be in line with direction of force

Talocrural Compression
-Stabilize distal tibia and fibula, press cranially on plantar aspect of calcaneus (note: will also compress
subtalar joint)
-Looking for pain provocation (glides looking more at mobility)
Inversion Anterior Talofibular ligament (FROM 524)
Stability -The examiner stabilizes the mortise with one hand and grasps the dorsum of the foot (at the neck of talus)
with the other hand then applies stress into plantarflexion, inversion and adduction
-Plantarflex and invert talus  looking for how it feels, comparing sides, and end feel
Calcaneofibular ligament (FROM 524)
-The examiner stabilizes the mortise with one hand
-With the other hand the examiner cups the heel and maintains the talocrural joint at 0° DF while applying an
inversion stress on calcaneous (inversion tilt of calcaneous)
Posterior talofibular ligament (FROM 524)
-The examiner stabilizes the mortise (especially the fibula) with one hand; patient in full DF (knee bent a bit)
-Need to rotate the talus externally
-With the other hand, thumb up on talus and cuping heel, dorsiflxs the talocrural joint maximally while applying
a lateral rotatory stress through the talus to externally rotate the foot (into more of a toe out position)
**Can also do assessment in prone
Dorsal Calcaneocuboid ligament
-Stand on medial side of foot
-Stabilize calcaneus and adduct/invert cuboid – picture the joint line and gap it

Lateral Talocalcaneal ligament (subtalar)

-Stand on medial side of foot
-Stabilize talus and invert plus gap lateral side of calcaneus
-Gap by pulling apart and creating space on outside of joint (calcaneous away from talus)
Eversion Deltoid ligament (anterior tibiotalar, anterior tibionavicular, tibiocalcaneal, posterior tibiotalar ligament; SEE 524 NOTES)
Stability -Stand on lateral side of the foot
-Stabilize tibia, move as follows into eversion:
Talus, in position of plantarflexion
Navicular, in position of slight plantarflexion
Calcaneus in neutral plantar/dorsiflexion
Talus in position of full dorsiflexion
Medial talocalcaneal (subtalar)
-Stand on lateral side of the foot
-Stabilize talus and evert and gap medial side of calcaneus
-Tilting the calcaneous to evert, then pull whole bone away to gap
Spring (Plantar Calcaneonavicular) ligament
-Patient standing and bearing weight on foot being tested, plantar force to head/neck of talus
-Palpate between head of talus and floor to feel talus drop
-May need to place a spacer (rolled towel) under calcaneous and navicular to test fully (with small gap in between)
 -With a complete rupture, would see marked asymmetry (complete loss of arch)

Ankle Accessory Movements (for assessment and graded for treatment)

*Stability test prior to accessory movements
*Progress to treatment if early loss of motion or early capsular end feel; treatment position may be different from assessment
Inferior Tibio- Anterior/Posterior Glides
fibular -Stabilize distal tibia with one hand, move fibula either anteriorly (using finger tips
behind fibula) or posteriorly (using thenar eminence in front of fibula)
-Plane of the joint is in the sagittal plane  have forearm IN LINE with force for glide
-Assessment = pt supine crook lying (can also assess posterior in side-lying)
-Treatment = pt in side-lying
Talocrural Anterior (PF) glide (FROM 545)
Resting position = -Stabilize distal tib-fib, pull talus anteriorly (avoid pulling through calcaneus), along the curve of the
10 degrees PF joint
-Assessment = pt in supine
-Treatment = supine or prone (making sure that hand is on posterior talus, not calcaneus)
Posterior (DF) glide (FROM 545)
-Stabilize distal tib-fib, push talus posteriorly along the curve of the joint
-Assessment & Treatment = pt in supine
-Can treat into more of the range you are working on, i.e. treating DF restriction with posterior glide,
then can start in more DF (not the open position)
-Can treat posterior with pt sitting with feet hanging off plinth, can move foot into more DF and posterior glide over edge of
bed
Subtalar Subtalar Joint (Bicondylar joint) Medial (inversion, supination) glide
(focus on moving -Posterior calcaneous is convex, anterior is -Stabilize across anterior talus
anterior concave = two compartments (anterior and -Moving hand is anterior to peroneal tubercle,
compartment) posterior)  when one compartment glides posterior to calcaneocuboid joint line to glide anterior
medially, the other calcaneus medially
glides laterally -Assessment = supine
-Calcaneous into -Treatment = Contralateral side-lying (shoulders overtop)
INV = talus moves Lateral (eversion, pronation) glide
laterally -Stabilize across anterior talus
-Calcaneous into -Moving hand is over sustentaculum tali to glide anterior
EV = talus moves calcaneus laterally
medially -Assessment = supine
-Treatment = ipsilateral side-lying (shoulders overtop)
Medial foot Plantar & dorsal glides of:
-Talonavicular  stabilize talus and glide navicular plantar and “medial rotation” [FOLD] OR
dorsal and “lateral rotation” [FAN]
-Navicular to medial cuneiform  stabilize navicular and glide cuneiform as above
-1st TMT  stabilize cuneiform and glide 1st metatarsal as above
-Steps = Stand on opposite side of the foot, hold proximal bone and move distal bone:
neutral to dorsal, then neutral to plantar
motion is almost like wringing out a towel (i.e. primarily plantar or dorsal, but glide has a slight rotary component
Lateral foot Plantar and dorsal glides of calcaneocuboid
-Stabilize calcaneus and glide cuboid plantar and “lateral rotation” [FOLD] OR dorsal and
“medial rotation” [FAN] Hands really close to eachother
*Name Rotation of bone based on where top of bone going in relation to body

INFORMED CONSENT = ‘the voluntary and revocable agreement of a competent individual to participate in a therapeutic or research
procedure, based on an adequate understanding of its nature, purpose and implications’ (Sim, 1996)
 Legally, informed consent respects the individual’s right to consent to being touched and has a bearing on a therapist’s
liability for negligence. A therapist may be found negligent for providing a treatment which results in an adverse response if
risks have not been disclosed and if knowledge of those risks would have influenced the patient’s decision to undergo the
procedure (Sim, 1996).
 Health care legislation in B.C. deems that informed consent must be secured if there is an element of ‘material risk’. A risk is
said to be material if “in the circumstances of the particular case, a reasonable person in the patient’s position, if warned of
the risk, would be likely to attach significance to it or if the medical practitioner is or should be aware that the particular
patient, if warned of the risk, would be likely to attach significance to it” (Grant 1996).
  Consent is particularly important with manipulative techniques because of the speed, which makes stopping the
technique beyond the patient’s control in the moment.
The process of obtaining informed consent
 The process involves discussion and communication with the patient. It is NOT just a signed consent form
 Information component: information about the procedure; benefits, risks, alternatives
 Comprehension: Does the patient understand? Are they capable of understanding?
 Oral or written consent

How is consent given?

Consent is implied when the actions of the person suggest consent. A patient performing a prescribed exercise is implying consent to
the treatment. Express consent occurs when the individual gives.

Talocrural Joint Traction Manipulation

 Peripheral joint manipulation refers to techniques which are of high velocity and low amplitude
Indications: Effects: Risks: Contraindications:
1. To restore end of range of -Possible tearing of post- -Tearing of soft tissues (other than -# in the area
ankle PF or DF when traumatic adhesions potential intended effect) – unintentional -Joint instability in the direction of the
mobilizations are no longer -Quick stretch to joint soft tissue injury-Post-treatment soreness manipulation
effective (last 5 degrees). capsule and stimulation of -# (unlikely for this manipulation) -Inflammatory joint disease -Malignancy
2. To gain last few degrees of mechanoreceptors  -Bone disease (osteoporosis, arthritis, etc.)
DF or PF when a noncapsular neurophysiological effect Cautions/Contraindications for novice -Open wounds, skin lesions in area
limitation of motion is present. manipulators: -Poor circulation or sensory deficit in the area
-Pain or instability proximally in the lower -Spasm or increased pain with a test pull
*The presence of an underlying kinetic chain (pre-manipulative hold)
hypermobility or instability -Uncertainty about indications for -Unsure of general health or diagnosis
should always be suspected technique -Patient does not want to be manipulated
and consequently the stability -Children (skeletal immaturity) (must explain procedure, joint noise, effects
of the joint should be retested -Diabetics -The elderly and ask patient for permission)
after manipulation. -For this technique, positive SLR on the -Patients on anticoagulants -Haemophiliacs
affected side -Inability of patient to relax -Physio factors
Manipulation Technique
Patient/PT Positioning: Steps Follow-up Treatment:
Patient should be comfortable, -Interlace fingers and place ulnar side of hands / 5th fingers over -ROM exercises, assuming joint is stable
supported, and have given head/neck of talus -Post-treatment soreness can occur; warn
informed consent -Keep forearms parallel to pt's tibia (this is your line of pull) patient, suggest the use of ice
Therapist should be sure of -Pre-manipulative hold: test pull is done by pulling along the line of -Balance, proprioception, strength, protected
good body and hand position, your forearms and assessing for pain/spasm; this is the final step in function
correct line of pull, low attaining informed consent -Taping, bracing if joint is unstable
amplitude with "economy of -Consent: Explain to pt that manipulation will be a similar movement
vigour"; don’t rebound or "back but will occur with speed. Make sure they understand and consent
up and charge". given before proceeding.
Supine, affected leg extended -Manipulation: take up the 'slack' by applying a traction force parallel to
with heel off the end of the the tibia  Apply a low amplitude, high velocity pull along the line of
plinth, your forearms by slightly extending your shoulders.
unaffected leg flexed -A slight click may be heard as the joint manipulates. Retest mobility,
stability

Mobilization with movement  Relative Posterior Glide

 Starting position = pt in lunge position above you on a raise plinth; have wall/person at side for stability
 Set-up = cloth on achilles tendon to prevent rub from belt, wrap belt around pt’s ankle (mobilizing tib/fib) and PT’s bottom,
stabilize pt’s talus anteriorly with a couple fingers under the medial foot to help hold up the midfoot to keep it in neutral,
line of pull between first and second rays
 Mobilization: do the glide by leaning back on the belt with the patient not moving (provide support at knee as needed) to
feel relative motion, then keep glide on and go down as pt follows into DF (to their maximal range), one you get to end
range stay there for a moment before releasing, looking for spot where it’s better
o Prescription: If it’s working  2 sets of 10 reps
 Things to consider:
o As move tib/fib anterior (into more DF), plane of motion for glide changes; want to be on tibia close to joint line
o Can be used as an ALTERNATIVE to talocrural manipulation!
 KNEE MANUAL THERAPY
Knee Classification Knee Biomechanics Close-packing of the knee Accessory Movements Tibiofemoral
-2 degrees of freedom Flexion “Screw home mechanism” =
(extension & flexion) -Posterior roll of femur new end extension the
-Closed packed position = -Posterior glide of tibia (arthokinematics) lateral compartment of the
end ext. w/ ER -Conjunct IR of tibia at end knee closepacks first
-Resting position = 30 flexion Extension (smaller, shorter anterior-
(how acute knee presents) -Opposite to flexion  anterior glide of tibia posterior diametre) and
-Capsular pattern = IR from neutral stops moving, while the
flexion>extension -Posterior glide of medial tibial condyle medial compartment can
-Normal end feels = capsular -Slight anterior glide of lateral tibial condyle continue to glide anteriorly
(extension), soft tissue ER from neutral (extend), creating conjunct
approximation (flexion -Anterior glide of medial tibial condyle tibial ER with full extension
-Slight posterior glide of lateral tibial condyle
*Note: lateral compartment comes to end range
before medial  only medial can be mobilized at
end range of flexion OR extension

Knee Assessment Overview:

 From 524  Lower Quadrant Scan, Observation, Functional Tests, AROM, PROM, Muscle strength/length, special tests
 New = Accessory movements
 Distraction/Compression  Looking for pain reproduction or relief
 *Glides  looking for quality, quantity, end feel and pain for assessment, graded for treatment
o Direction of force along forearm / Go around the fibula to tibia on lateral side
o Take time to pick up slack, move muscle out of the way, get on bone, then start glide

Tibiofemoral (Knee) Accessory Movements

General Tibiofemoral Distraction:
-In resting position (supine) or 90º flexion (sitting)
-One or both hands on proximal tibia (+/- fibula), pull along line of tibia
Tibiofemoral Compression (In resting position)
-Cranial hand stabilizes femur, caudal hand creates a compressive motion to the knee joint via proximal tibia
-Note: rarely used for treatment, more as a pain provocation assessment technique, sometimes considered a stability test but again
more about symptom production than laxity or end feel.
Posterior Whole tibial plateau
Glides* -Posterior glide of the whole tibial plateau to assess or facilitate flexion (in rest position).
-Cranial hand stabilizes posterior aspect of femur, caudal hand glides tibia posteriorly following the curvature
of the joint to avoid creating a posterior shear or drawer
Medial compartment
-Posterior glide of the medial compartment of tibia at rest position or end flexion to assess or facilitate tibial IR or
end flexion – hands as above  Lumbrical grip to gather up soft tissues
Lateral compartment
-Posterior glide of lateral compartment of tibia at rest position to assess or facilitate tibial ER – hands as above
-Easier if done from contralateral side
Anterior Whole tibial plateau
Glides* -Anterior glide of whole tibial plateau to assess/facilitate extension (in rest position)  think about
movement of condyles
-Cranial hand stabilizes anterior aspect of femur, caudal hand glides proximal tibia anteriorly following
the curvature of the joint to avoid creating an anterior shear or drawer
-Wrap caudal hand around and pick up calf to move it out of way, then grasp around tibia
Medial compartment
-Anterior glide of the medial compartment of tibia at rest position or end extension to assess or facilitate tibial ER
or end extension (“screw home mechanism”) – hands as above

Lateral compartment
-Anterior glide of the lateral compartment of tibia at rest position to assess or facilitate tibial IR – hands as above
-Easier if done from contralateral side
 HIP – MANUAL THERAPY
Hip Classification Hip Biomechanics Arthrokinematics Hip Joint pain referral
patterns (L3 dermatome)
-Resting position = 30 -Proposed to follow -ER = Anterior (medial) glide -Buttock = 71%
flexion, ABD, slight ER concave/convex joint rules -IR = Posterior (lateral) glide -Thigh (anterior, lateral,
-Closed packed = Ext, -*Oblique orientation of the joint -ABD = Inferior (medial) glide and/or posterior) = 57%
ABD, IR (toe off in gait)  Acetabulum faces down, -ADD = Superior (lateral) glide -Groin (inguinal) = 55%
-Capsular pattern: lateraly and anteriorly *Medial/lateral component due to obliquity of acetabulum -Distal to knee = 16%
Flexion, ABD, IR   Femoral  try to follow joint angle -Foot = 6%
generally unilateral loss head faces -Flexion & Extension = no glide, just pure spin -Knee = 2%
of IR most significant up, medially  Flexion tightens posterior capsule, if posterior capsule
and slightly excessively tight it may push femoral head anteriorly 
posteriorly glide femoral head posterolaterally to stretch posterior
capsule to free up flexion
 Extension limit  myofascial technique most effective

Hip Assessment Overview:

 From 524  Lower quadrant scan, Gait, Balance, Single leg stance, squat clearing test, AROM/PROM, MMT/length
 New = Passive Accessory Movements + Combined Movements!

Sign of the buttock:

 Painful or limited strength leg raise even with bending the knee
 No change in hip flexion ROM with knee flexed
 Empty end feel
 Red, hot, swollen buttock
 * Things not looking quite right  pain not changed by position of movement, lots of resting pain, hx does not quite fit
 Causes =R(rheumatic bursitis), O(osteomyelitis of upper femur), Neoplasm (femur, sacrum, or ilium), F (fractured sacrum), I
(ischiorectal abscess), S (septic arthritis), S (septic bursitis) = RONFISS

Hip Assessment & Treatment Techniques

*With all manual techniques for hip  stabilize and localize precisely to avoid undue stress on lumbar spine + pelvis

Hip General Articular Techniques

Distraction -Both hands placed as proximally as possible on femur (trochanter and proximal inner thigh) with movement applied
infero-laterally along the line of the neck of femur. Pelvis is not directly stabilized, but feel carefully with your hands
and watch for the onset of movement of the pelvis to know when the limit of the distraction has been reached.
Looking mostly for symptom reproduction or relief
Assessed in the rest position
Can be graded (I – IV) for treatment  may be indicated for very irritable hip (grade 1-2 distraction)
Can be used for treatment at any point in the range, though note the potentially altered orientation of the
femoral neck and therefore your line of pull. A mobilization belt placed around the patient’s proximal inner thigh
(cushioned) and back of therapist’s pelvis can be useful for treatment.
*Using arms a lot for this one! Arm on inside of thigh doing most of the work
Compression -As per distraction, with hip in the resting position, but with movement applied supero-
medially along the line of the femoral neck (Hands can be in same position)
-Alternate hand position =proximal hand on greater trochanter, distal hand on opposite
ilium. Compress along line of femoral neck.
For assessment = symptom reproduction more likely than relief

Long leg traction -More of an inferior component, different from regular distraction
-Both hands on distal femur, above flare of epicondyles. Create a pull along the line of the shaft of the femur. Pelvis
is not directly stabilized, movement of the pelvis to know when the limit of the longitudinal movement has been
reached.
-NOTE: This is a non-physiological movement  may distract the superior portion of the joint surface, while
creating some kind of inferior glide which does not follow the plane and curvature of the joint.
Assessed in the resting position May be graded for treatment
Grade 1-2 physiological -Treatment only  for pain relief when treating an acute joint
rotation in rest position -Process = general oscillatory technique in resting position (grade 1/2) >
IR/ER motion with hands on distal femur
Hip Accessory Movements (For assessment and/or graded treatment)  glides = how far, quality, end feel etc.
Posterior glide  IR -Set-up: Pt in supine, hip in rest position for assessment
restriction -May facilitate flexion by bowing tight posterior capsule
-Process: Stabilize pelvis with cranial hand, mobilize femoral head using palm of hand over the
middle 1/3 of the inguinal ligament (humeral head will be directly beneath)  Push in a
posterolateral direction following the curvature of the joint.
-Can come onto ilium at back, then over femoral head anteriorly (need to get them to relax hip
flexors
*May be done in 90° of flexion to assess for, or treat, a tight posterior capsule
Posterior glide @ 90 -Used to stretch posterior capsule  often used in loss of end range flexion esp. if anterior
degrees flexion  tight impingement
posterior capsule -Rarely used in acute hip pain i.e. lower grades of mobs
-Creating posterior vector with both hands and shoulder (have to get them low enough so you can
get over them)
-Put them into position of restriction
-May need some more flexion and adduction depending on pt  come down onto bone then take
them posterior and lateral
-Other handling option = hands wrapped around leg, distracting then posterior/lateral (can use belt for this method)
Inferior glide  ABD -Set-up: pt in supine, hip in rest position for assessment
restriction -Process: Both hands as proximally as possible on femur (trochanter and proximal inner thigh), glide
infero-medially following the curve of the joint. Pelvis is not directly stabilized, but feel carefully with
your hands and watch for the onset of
movement of the pelvis to know when the limit of the glide has been reached.
-Try to get more contact with hands (not just ulnar border of hands), sink down into muscle!
Superior glide  ADD -Set-up: pt in supine, hip in rest position for assessment
restriction -Process: As per inferior glide, but direction of movement is superolateral

Anterior glide  ER *Be very careful in situations of anterior impingement (FAI), “click” or suspected hypermobility
restriction -Set-up: Patient is prone over pillows to maintain rest position of the hip with knee outside of ankle (some ER), proximal
hand stabilizes/monitors the ASIS, palm of distal hand is as proximal as possible on the femur (just below gluteal fold) 
landmark greater trochanter and ischial tuberosity, then drop into the middle + somewhat cranially to land on femoral
head; position yourself
-Process: Movement is applied in an antero-medial direction; PT positions themselves so shoulder over pt to apply a
direct forward + medial vector
Combined Movements, -Note: these are more aggressive FADDIR
Quadrants techniques, suitable for the non- -Flexion, ADDuction, Internal Rotation of hip joint, moving femur from distal
irritable, stiff hip and indicated when the end, posterior side i.e.
pain seems to be articular but has not behind knee, with distal hand.
been reproduced with straight planar -Take patient’s leg through an arc of motion, assessing for pain, ROM and
movement testing or glides smoothness of arc
FABER
*Can also be used as oscillatory -Flexion, ABduction, External Rotation with same hand positioning as above
treatment for non-irritable hip restriction  arc of motion!
(either high grade or low grade) -NOTE: this is different from a FABER’s test
Hold/relax or -Localize movement to the hip joint. The pelvis should not appear to move at all.
contract/relax into -Choose a muscle contraction based on direction or muscle group to be facilitated (decreased strength or recruitment) or
restricted ROM inhibited (overactivity) or re-educated (recruitment in end range)
 THORAX MANUAL THERAPY
Thoracic Anatomy Thoracic Biomechanics
Spinal: Kyphosis / Planar z-joints (facet joints) / Steeply angled spinous Spinal (z-joint):
processes (specifically in mid thoracic region) / thin dics -Flexion = anterior role, anterior shear  Cranial glide
Articulations: -Extension = opposite to flexion
-Coronally orientated z-joints -Side flexion/rotation  ipsilateral caudal glide / Contralateral cranial glide
-Costovertebral joints (vertebrae of same number and one above  ribs -Shoulder flexion = drives thoracic extension, ipsilateral rotation/side flexion
1,10,11,12 only articulate with vertebrae of same level (both facets glide inferiorly with shoulder flexion = extension of facets)
-Costotransverse joints  not at ribs 11,12 Ribs:
Rib Cage: -Anterior or posterior roll (osteokinematically and at costovertebral joint
-12 pairs of ribs (spin))
-Vertebral and sternal (or chondral) attachments -Cranial or caudal glide against TVP (costotransverse joint) with all
-Ribs 2-9 attach to two vertebral levels movements of torso or respiration
-Sympathetic trunks just anterior to heads of ribs  sometimes when Inhale = posterior roll (pump
assessing/treating thoracic spine can get sympathetic response in pt = handle i.e. sternum up)  inferior
sweating, increased HR, general feeling of unease, nausea  choose glide
different technique w/ pt Exhale = anterior roll (pump
Functional Unit – One segment includes: handle down)  superior glide
-Vertebrae, articulating on vertebrae below: -Pure spin at costovertebral joint
 Articulations = 2 z-joints (coronal plan), interbody joint (disc) -Generally, feel how one rib
-Right and left ribs of same level moves vs. ribs below/above/other
 Articulations = 2 costotransverse joints (can get directly on), 2 side
costovertebral joints (can indirectly affect), 2 costochondral joints (indirectly
through back), 2 sternocostal joints (indirectly through back)
 Thoracic Surface Anatomy
Ribs 2-12 TVPs Spinous Processes
-The rib angles form the posterior prominences of the skeletal thorax lateral to -Follow rib medially to find the rib angle (most -Counting up from the
the spine prominent posterior bump on rib)  palpate + L5 spinous process or
-The upper ribs are more easily palpated when the scapulae are abducted (or drop down deep into erector spinae muscles -Having the subject
protracted). medially extend their neck and
-As you move caudally in rib cage  rib angles diverge, ribs become oriented -Should “butt up” against lateral end of TVP head to identify C6
more obliquely (need to get up on it for PA’s) and counting
-The second rib angle is the most cranial bony landmark along the rib angle - Directly medial to the posterior aspect of the down
line, cranial to the root of the spine of the scapula (lateral to the TP of T2). rib of the corresponding number
-The first rib is a flat platform at the base of the neck. (i.e. the TP of T7 lies horizontally adjacent to
-The 12th and 11th ribs can be found by identifying the SPs of T12 and T11 the most
and palpating for a bony landmark just lateral to the vertebra. (The 12th rib tip postero-
can also be palpated through the postero-lateral musculature and the rib medial aspect
can be palpated along its posterior edge as you move medially towards the of the 7th rib)
spine and slightly cranially.)

Thoracic Scan
Subjective:
 All the usuals (pain, paraesthesia, behaviour through day, agg/easing factors
 Relation to exertion (cardiac issues or due to increased respiration and resultant
increased volume demands on rib cage), eating (visceral referral), lifting
(compressive load), coughing, deep or normal breathing
 Cord symptoms (bilateral, quadrilateral) or other LE neuro symptoms
 Posture, ergonomics of work/leisure
 Mandatory Questions:
o Bilateral/Quadrilateral signs and symptoms
o Pain on general exertion (?cardiac)
o Symptoms related to eating (?visceral referred)
o Symptoms related to breathing (differentiate rib mobility problem from lung pathology)

Objective (Scan)
1. Posture -Standing then sitting – Spinal, head position, rib cage shape
2. ROM -AROM  No overpressure here as end feel from a number of joints  clear range and see how it feels for pt
 Cervical (when indicated, start here) = flexion (chin to throat + chin to chest), extension, rotation, side bend
 Shoulder flexion
 Thoracic = extension, flexion, rotation with arms across body, side bend
3. Resisted Trunk -As appropriate to provide important information to inform treatment
4. Respiration -Assessing breathing pattern -Ask for deep breath and looking for lateral costal movement (NOT all apical or belly)
5. Traction -Process = pt arms very tight across front to tension up patient, come up onto bottom arm and gather them up
tight, then pull pt into you like a hug and then stand up  movement is superior-posterior
-Looking for pain provocation or relief

6. Compression -Process = arms folded again (like traction), lower the bed right down, up and over pt, then add load inferiorly
-Looking for pain provocation or relief

7. Neural Conduction -LE reflexes -Plantar response, clonus -What about testing in the trunk?
8. Slump (SEE ABOVE)
9. P-A Springing -Posterior  Anterior sprining of spinous processes and rib angles 2-10
-Should be provacative  looking for symptoms, just straight down
-Quick push (not large amplitude)
-Landmark C7, then move down onto thoracic
10. Facilitated Segment -Skin drag  looking for local change in swelling or if stick in one point
-Scratch test  looking for asymmetry of scratch on either side
-Peau d’orange (skin rolling)  looking for spots where it sticks
 Thoracic Manual Assessment & Treatment Techniques
Passive Intervertebral Movements (PIVMs) = passive range of motion of an intervertebral joint (i.e. T5/6)
-These techniques work well from T2 to T10. PIVMs are not dangerous assessment or treatment techniques in patients with osteoporosis.
-3 fingers on at all times, either on spinous processes OR interspinous spaces
-Stabilize feet to help not get motion through full spine (don’t want them moving through lumbar spine)
-Stand on side where arm is underneath, get in close
-Just feeling with hands on the back, expecting a few degrees of movement each way
-Has no context unless you compare to levels above and below to see if relative motion is impaired
Seated Patient: Seated at end of bed with arms folded across shoulders  PT at pt’s side and reach across pt’s
Flexion anterior thorax between pt’s folded arms to opposite side  PT’s hand over pt’s hand in line with level to be
PIVMs tested, with other hand place 3 fingers either on spinous processes or interspinous spaces, middle finger on
segment to be tested
Process: Flex pt gently using your body and other arm, focusing the movement at the desired level (think of
tucking in at that level from front)  feel spinous processes separate, when inferior vertebra begins to move
superiorly = flexion taken up at that segment
*No movement should be felt under middle finger
Seated Patient: set-up is same as seated flexion PIVMs
Extension Process: Extend pt gently using your body and the other arm, focusing the movement at the desired level  feel spinous processes
PIVMs approximate, when inferior spinous process begins to move inferiorly = extension taken up at that segment
Seated Patient: set-up is same as seated flexion PIVMs
Rotation Process: Rotate pt toward you using your body and the other arm, focusing the movement at the desired level  feel superior
PIVMs spinous process move away from you (and away from the inferior spinous process), when inferior spinous process begins to move
away = rotation complete at that segment. Move to pt's other side to feel the opposite rotation.
*****SIDE FLEXION
Seated SF Patient: set-up is same as seated flexion PIVMs
PIVMs Process: Side flex pt away from you using your body and the other arm, focusing the movement at the desired level  feel superior
spinous process move away from you (and away from the inferior spinous process), when inferior spinous process begins to move
away = side flexion complete at that segment. Move to pt's other side to feel the opposite side flexion.

Passive Accessory Vertebral Motion (PAVM) = passive accessory motion  i.e. superior or inferior glide of facets etc.
*Caution is advised with the following (for assessment or treatment) if the patient is osteoporotic
-Use thumbs or pisiform
-Treating areas where there is decreased mobility, compare to levels above or below
-Looking for quality of movement, quantity of movement, end feel, and pain provocation
1. Postero-anterior (P/A) -Cranially directed for flexion
pressures to the spinous -Straight PA for extension (in cases of significant thoracic kyphosis, a “straight” PA is
processes (PAVM) perpendicular to the thoracic curve, not to the floor)
(Low bed to get shoulders over)
2. P/As to the transverse -Cranially directed for flexion, contralateral side flexion or contralateral rotation
processes (PAVM) -Caudally directed for extension, ipsilateral side flexion
(Low bed to get shoulders over)

3. Transverse pressure to either -For rotation: if pressing SP from the right side toward the left, you will be assessing right
side of the segmental rotation
spinous processes (PAVM)

4. P/As to the posterior aspect -Caudal PA rib w/ TVP stabilized in a cranial direction
of the ribs -Cranial PA rib with TVP stabilized in a caudal direction
(medial to rib angle) (PAM) -Compare levels above and below  Treat the limitations!
-PT positioning = thumbs parallel to spine, elbows out and applying pressure with
gliding thumb on rib while stabilizing with other thumb on TVP  Reach over to
opposite side of plinth, sink deep into muscles, bed low
Thoracic Stability Tests (Named based on what you’re doing to the cranial bone)
Anterior Translation -Set-up: pt prone on plinth
-Process: PT use key pinch grip of thumb and index finger or knuckles of caudal hand to
take up the slack and stabilize the caudal vertebra, pinching the TVPs; shoulders right
over tip of where you’re working w/ bed low  Use pisiform (on spinous process) or key
pinch (on laminae) of cranial hand to create a straight anterior pressure on the cranial
vertebra  Sustain for 10 seconds
-Assessment: Assess for quality of motion (how smooth is the motion?), quantity of motion
(how far does it go?), end feel (what stops you at the end, i.e. soft tissue, spasm, bone,
etc.?  should be bony)
-Positive = give that you didn’t feel at level above/below, pain, muscle spasm, sympathetic
response

Posterior Translation -Set-up: pt seated on the end of the bed with arms folded across shoulders, feet stabilized
with stool, bed high
-Process: PT stands close at pt’s side and reaches across pt’s anterior thorax between pt’s
folded arms to the opposite side of the thorax (often desirable to have therapist’s hand
over patient’s hand, against the rib cage, placed approximately in line with the level to be
tested; similar to PIVM)  Use key pinch, thenars or knuckles across the caudal vertebra
to stabilize it and prevent it from being pushed posteriorly (forearm perpendicular to spine) 
Shear posteriorly through the trunk by adducting your arm at the front of the patient’s thorax.
-Positive = reactive muscle spasm, symptom reproduction on sustained hold

Thoracic Treatment Techniques

Traction – General -Set-up: pt crosses arms across chest (hands to shoulders)  arms in ‘V’ position
-Process: PT grasps both of pt’s elbows in hands, compresses pt’s arms into pt’s torso, PT in stagerred stance 
PT adducts his/her own arms and creates traction effect by straightening legs  movement = anterior-posterior

Traction - Specific -Set-up: Roll a small towel and place it on the spinous process of the cranial vertebra of the level to be
treated (vertical or horizontal towel placement). Patient crosses arms across chest (hands to shoulders).
-Process: PT grasps both of pt’s elbows in hands, compresses pt’s arms into pt’s torso  PT adducts
his/her own arms (in effect making patient’s cranial vertebra, PT and intervening towel one unit) 
creates traction effect by straightening legs or just leaning back slightly (There is no need to lift your
patient!) (essentially lifting upper bone and everything above off of lower bone)
-Looking for pt response = should feel better
MAY NOLAN’S SECTION
LUMBAR SPINE MANUAL THERAPY
Lumbar Anatomy Review:
 Looking at lumbar spine in terms of segments  one segment = two vertebrae and disc between them
 Anterior Longitudinal Ligament (ALL) = flat and broad ligament across front of disc  lesions are very rare (if they even
happen again); provides nice restraint to anterior translation and traction like forces
 Posterior Longitudinal Ligament (PLL) = narrow over disc but broad over vertebrae; most deficient posterolateral due to
anatomy
 All longitudinal oriented ligaments will have restraint on traction, posterior, and anterior movement
 Disc = multiple layers; each layer perpendicular to next layer > provides a primary restraint to rotation, somewhat also to
traction; disc also supplies some compressive force as pressure on disc adds pressure to nucleus pulpous which then creates
more compression (in intact disc)
 Compression loads up disc and facet; shear and torque forces load up disc

Lumbar Biomechanics:
 Lumbar spine movements = flexion, extension and sideflexion coupled with rotation; primary movements = flex/ext
o Not capable of pure sideflexion or pure rotation This means that the lumbar spine is not capable of pure
sideflexion or pure rotation due to shape of the facet joints  Either movement can be initiated but there will
always be a component of sideflexion with rotation and vice versa
o Literature varies as to whether coupling is ipsilateral or contralateral  L5 = ipsilateral
 *Rotation always described according to what the front of the bone is doing and also refers to the superior vertebra of the
segment  Ex) right rotation of L4/5 means that L4 is rotating to the right relative to L5 (not relative to L3) ie the anterior
surface of 4 rotates to the right (therefore the spinous process goes to the left)
Movement Osteokinematics (movement of a bone) Arthrokinematics (joint glide i.e. ‘z’ joint)
Flexion Anterior saggital rotation, anterior translation Anterosuperior  increased IVF space
Extension Posterior saggital rotation, posterior translation Posteroinferior
R side flexion Inferior movement right side of vertebrae Inferior glide at the right, Superior glide at the left
R Rotation Gapping of right facet joint, compression of left facet joint Depends on coupling w/ sideflexion, whether it is
ipsilateral or contralateral

Lumbar Spine Assessment:

 2 components = scan + detailed articular assessment
 Scan must be performed on every single pt presenting with low back pain!
 The scan has both subjective and objective components and is vital to determining the following:
o Rule out serious pathology (i.e. note any red flags from the subjective or objective components)
o Determine whether physiotherapy is appropriate or the patient should be referred to their doctor or co-treated
o Focus the objective examination and treatment on the appropriate region i.e., lumbar spine (upper vs lower) or
lumbar spine vs knee
 Components of scan = subjective Qs pertaining to MSK, neuro, and systemic health; general mobility, general stability, neural
conductivity, neuromeningeal (dural) tests, vascular tests and lower quadrant screening (scan of MSK & neuro systems)
 Order of scan depends on pt’s symptoms  save most provocative movements for the end
 Try to do all standing tests together, all sitting tests together, etc. (for pt comfort and to minimize false positives)
Lumbar Spine Scan
SUBJECTIVE – Subjective Hx SUBJECTIVE – Mandatory Questions
 Age  Improving? Getting worse? Bladder / bowel dysfunction, saddle paraesthesia,
 Occupation  PMHx. anaesthesia, effect of cough / sneeze, neuro
 P/C Forces involved e.g.  FHx. symptoms? Why?
Flexion, rotation, traumatic /  General Health -Red flag questions
insidious onset, pain  Meds -Concerned about spinal cord/cauda equina
location  Investigations AND results -Neuro symptoms = referred pain, numbness/tingling; if
 Diurnal variation someone has neuro symptoms but no neuro signs then
 Sleeping affected? Position / Pillows
 Aggravating factors it's not as problematic
 Sports / Activities
 Easing factors  Previous treatment and results

Lumbar Spine Scan – OBJECTIVE (Should be able to complete this objective scan in 10 mins!!!!)
Standing Sitting Supine Prone
Observation (i.e. café au lait, creases, abnormal hair tuft Slump test* SLR** Femoral nerve stretch
etc.) L3, S1 Myotomes L2, 3, 4, 5 (don’t always (FNS) /Prone Knee Bend
Active mobility tests (observe creasing, hinging around a reflexes do L2 as loads up spine) (PKB)***
segment, ability / willingness to move, how the patient Resisted Dermatomes L2, 3, 4, 5 (swipe/dab Myotomes S1, 2****
moves) tests (if along entire dermatome) Dermatomes S1, 2, 3, 4,
Flexion / extension / sideflexion / rotation (Combined appropriate, do General Traction (not through Farfan’s general torsion
movements if appropriate; don’t overpress) not do if acute) knee/feet if knee injury) test
Squat test for LE peripheral joint screening (if no General Compression Facilitated segment tests
contras) Plantar response (skin rolling, scratch test,
Pelvis; Kinetic tests Clonus (normal =1-2) pitting edema, two-finger
S1 myotome = 10x calf raises (relatively rapid) Pelvic stability tests (SI drag; often not included)
Resisted tests (Rarely used in scan as true isolated Contraction, distraction etc.) S1 reflex
muscle tears or strains are rare and resistance could Pulses
potentially agg disc or facet joint esp if acute) FABERS

*Can start with either neck flexion or thoracic flexion  be mindful if a specific area is more irritable i.e. if neck more irritable then
start with thoracic flexion before proceeding to neck; only do this test if it’s appropriate; hands always behind back to standardize

**Good stand-alone assessment; if restricted/positive findings between 30-60 degrees of hip flexion = likely a disc issue; sensitizing
aspects help to determine if dural, while contract/relax or end feel (muscular) would indicate more likely hamstring

*** Normal = 10-15 hip ext, 90 knee flexion  May need to apply more knee flexion to stress the dura in a really mobile pt; Positive =
limited ROM relative to other side +/- pain/neurological symptoms anywhere from ipsilateral, contralateral leg or lumbar spine

****If for some reason could not test with calf raises, then could test hamstrings for S1,2; can also get them to contract glutes and
palpate bilateral differences; if clear calves then don't have to do prone knee flexion

Farfan’s -Set-up: pt prone lying

General -Process: PT fixes spine at thoracolumbar junction, grasps ASIS
Torsion and by lifting up right ASIS produces left rotation of the lumbar
Test spine. This would be called a left torsion test. It is a general test
and goes through multiple segments. Normal to have better ROM
in one direction. (OVERALL rotation assessment)
-Positive = pain (back or leg), spasm end feel, excessive ROM

Then determine if you are treating a stiff joint or a hyper mobile joint or whether the problem is a combination of both (e.g. a stiff
hip could cause a hyper mobile lower lumbar spine or a stiff L4/5 could contribute to a hyper mobile L3/4)
 If a joint is stiff then mobilize according to patient presentation (consider acuity and irritability)
 If hypermobile, then stabilize with exercises +/- external support, if indicated.
(These principles apply to every joint in the body)
Summary of Neurological Exam (Scan) The neurological exam consists of Subjective and Objective components:
 1) Subjective exam: Pain, pins and needles, numbness. Note distribution of symptoms? Spinal? Peripheral nerve. Note
aggravating and easing factors, i.e. related to positioning e.g. extended lumbar spine or time of day (early am may indicate
inflammation), cord and cauda equina questions.
 2) Objective Exam: The objective exam has 2 components, nerve conduction and nerve mobility tests:
o 1) Nerve Conduction Tests – these tests are for Myotomes, Dermatomes and Reflexes (spinal cord and peripheral
nerve)
o 2) Nerve Mobility Tests – the primary tests are Slump, Straight Leg Raise (SLR) and Femoral Nerve mobility
(sometimes called prone knee bend test or PKB).

Spinal Cord Reflexes

Plantar Response and Clonus tests are tests of spinal cord conduction. A positive plantar response (Babinski) indicates an Upper
Motor Neuron Lesion. 1-2 beats of clonus are normal in the adult population over 40.

Hard Neurological Signs

 Hard Neuro signs = loss of myotome and/or reflex and/or sensation  impairment of nerve conduction
 Potential causes = disc pathology, inflammation around the nerve root, spinal stenosis, lateral or foraminal stenosis.
 More care is needed in treatment (can still treat them!), monitoring of signs is essential and the doctor should also be
informed w/ these pts .
 Patients presenting with nerve irritation  likely to improve more rapidly (loss of conduction takes a lot more time to heal)

Impairment of Nerve Mobility

 Positive Slump, SLR or PKB = need to be monitored
 If they are accompanied by hard neuro signs of loss of conduction  patient is likely to have a significant disc pathology or
spinal stenosis
 If there are no signs of loss of conduction  impaired mobility may be due to swelling or inflammation around the nerve root
which may recover quite quickly

Mechanical vs. Inflammatory signs & symptoms

Mechanical Inflammatory
Symptoms Mechanism of injury First 24 hrs post injury or may not be as a result of
injury (i.e. RA)
Specific aggravating factors Worse in morning or after immobilization
Specific easing factors Better with a little rest but worse with prolonged rest
Predictable patterning Better with a little mobility but worse with too much
movement
Signs Pain with selective tissue tension tests Red / hot / swollen
I.e. if muscle  pain w/ resisted testing; if ligament  pain with Acute inflammation can also cause decreased
stability test; if tendon  pain with eccentric component of test mobility
Detailed Biomechanical Exam of Lumbar Spine = MOBILITY TESTS (PIVM, PAVM) and STABILTY TESTS (compression, traction,
torsion, anterior shear, posterior shear)
 What affects ROM at a joint?  tight capsule, scar tissue, muscular restrictions, pain, articular restrictions
 End feel dictates treatment  i.e. hard bony end feel = may not get extra movement out of it
 Stiff = mobilize; Hypermobile = stability exs, DON’T mobilize
 *Back off on lumbar spine vs. thoracic
 ***When there’s a joint restriction  accessory glide is confirmation test!!!
Mobility Tests  Note Quantity of movement, Quality of movement, End feel (move in and out of available ROM)
PIVMs -Assesses passive physiological motion of the intervertebral segment  Tests whole motion segment
including joint, capsule, ligaments and disc.
-Set-up: pt side lying at edge of bed; ensure neutral spine w/ towel under waist if necessary (usually for
females); hips + knees flexed, supported on the PT's abdomen; bed height at PT’s ASIS (use legs!)
-Process: PT standing facing the patient  With caudal hand, support the patient's legs (either behind
knees or closer to feet)  With index finger of the cranial hand, palpate the interspinous space of the
segment being tested  Also palpate the interspaces above and below to isolate to
that segment
Technique for testing Flexion from T10 - S1: Movement = use hip flexion to passively
flex the joint complex about the appropriate coronal axis until you start to feel the
tension  Feel the gap at the interspinous space Repeat this test for each
segment (usually easiest to start at L5/S1)
To test Passive Physiological extension: Movement = Passively extend the joint
complex about the appropriate coronal axis and feel the spinous processes coming
together Repeat the test for each segment and compare segmental mobility.
(Usually easiest to start at the TL junction and move caudally)
PAVMs -PAVM = PA Pressures  Passive accessory mobility assesses the facet joint glide component of movement  confirm PIVM
findings
-NO PA pressures in presence of Spondylolisthesis, fracture, infection or neoplasm (at the specific segment)
-Caution w/ PA pressures in the presence of Osteopenia, osteoporosis, inflammation, active cancer, acute trauma.
Assessment:
-Used as a mobility test or a provocative test (i.e. seeing if pain and spasm is provoked)  mobility test assess the joint play and
compare with the levels above and below and with clinical experience compare with age matched ‘controls’ (i.e. clinical mileage).
-Determine the quantity or range of motion and decide if the joint is normal, hypo mobile (restricted) or hyper mobile (excessive).
-Process:
Oscillate through total available ROM - go to end feel, not beyond  Repeat 3-4 times
Release pressure back to start point, but don’t lose contact with spinous process (i.e. don’t bounce off the tissues)
Treatment Technique: Graded, to reduce pain and to mobilize restriction (graded I – IV as per Maitland)
Choose appropriate grade (see treatment section)
Think of that grade throughout treatment and do continuous oscillations for 1 ½ min, then reassess
PA Central Pressure  to assess and or treat joint mobility for the movements of flexion /
extension
-Set-up: pt lies prone, arms by side, head of bed declined to reduce extension through spine
-Process: PT stands at side of pt with pads of thumbs (or pisiform) over selected spinous
process, elbows slightly flexed  sink into tissue to get onto bone, maintain contact
throughout  movement produced by pressure applied from PT’s body, transmitted down
through the arms to the thumbs (or pisiform)
 Pressure slightly cranially for flexion
 Pressure slightly caudally for extension
PA Unilateral Pressure  to test joint mobility for sideflexion / rotation and to determine whether one ‘Z‘ joint
is stiffer or more painful than the other side.
-Set-up: pt lies prone, arms by side; PT stands at side of patient with pads of thumbs (or pisiform) over
selected z joints or articular pillars (over TVPs if articular pillar too sensitive), elbows should be slightly flexed
*Landmark articular pillar  thumb on spinous process, perpendicular to spinel, move laterally to DIP =
articular pillar location
-Process: Movement produced by pressure applied from the PT's body, transmitted down through arms to the
thumbs (or pisiform).  Angle slightly cranially or caudally depending on movement being assessed  E.g.,
left cranial unilateral to test RSF
Stability Tests
-Clinically, subjective symptoms of instability = apprehension/fear of movement, feel unstable/like it will give way, pain with prolonged positions/
certain extremes of movement, pt complains of clicking/popping
-Segmental instability = might observe compensation, may posterior pelvic tilt (more stable), muscle guarding, not full ROM type guarding, use
hands to walk up on legs, use hands to stabilize as bend down
**If general compression, traction, Farfan's clear and subjective/objective does not indicate  WON’T ASSESS STABILITY
Compression -Subjective complaints = increased pain with sitting, flexion or weight bearing activities
-Primary restraints compression = disc, some facet joints
-Set-up: pt supine crook lying
-Process: PT supports patient’s legs, passively flex patient’s knees toward chest can add axial
compression through femur or ischial tuberosities
-Positive = pain in the back or leg, spasm or empty end feel, limited ROM
*sometimes this test will not reproduce the patient’s symptoms, especially if it takes 20 minutes of sitting
to reproduce their pain
Distraction -Primary restrains to traction force = disc, longitudinal ligaments
(Traction) -Set-up: pt supine, knees flexed
-Process: PT applies a traction force to the lumbar spine from behind the calves or alternatively through
the thighs if there are any problems with knee stability (i.e. Anterior Cruciate Ligament laxity or repair)
Specific traction can also be tested at an individual segment if indicated

Torsion -Set-up: side lying, close to edge of bed; PT palpate at level to be assessed (start at L5 S1 segment)
(Specific/ -Process: Cranial hand - thumb applies pressure toward floor on superior vertebra’s SP  Caudal hand - fingers come under
Segmental) SP of inferior vertebra  Fix top vertebra, pull forward through bottom one to induce torsion OR fix caudal vertebra and apply a
transverse pressure to the top vertebra to induce rotation  Rotate spine about a pure vertical axis, until the end feel is reached
-The torsion being tested is named according to what the front of
the top bone in the segment is doing i.e. pt lying on R side,
generally always L rotating
-Amount of movement should be minimal i.e. immediately jams =
anterior stability test
-Disc = primary restraint to rotation  right rotation, then right
facet gets gapped, left gets compressed
Anterior -Subjective complaints = pain is aggravated by prolonged standing and / or sitting
Translation -Set-up: pt side lying, close to edge; PT palpate level to be assessed
-Process: flex both legs up to level below that to be tested  SP of superior vertebra is
fixed to prevent posterior motion (pull toward you/anterior force)  posterior force is
applied along the femur to shear the inferior vertebra posteriorly under the superior
producing a relative anterior translation at the segment (Alternative technique = apply
sustained P/A pressure to the cranial vertebra in the segment and attempt to stabilize the
inferior vertebra)
-Anterior translation restraints = ALL, disc, facet joint capsule, ligamentum, flavum, inter + supraspinous ligaments (same for
posterior, but start at the end of list
Posterior -Set-up: patient sitting, arms across chest; PT stands to the side of the patient 
Translation One hand fixes the inferior vertebra to prevent posterior motion (applying some
anterior pressure) and palpates for translation
-Process: Other arm wraps around the patient (slightly cranial to segment testing,
arm over pt’s arm) and provides the posterior shear motion to the trunk, attempting
to localize the motion to the segment being tested
 Once slack is taken up along spinous process of caudal vertebrae, then very
little posterior movement
-Alternative technique can also apply a P/A to the caudal vertebra to produce a
relative posterior shear
May stabilize the cranial vertebra to try and localize the force to the desired level
Must differentiate from an anterior shear at the segment below

 When would you send someone to DR for further imaging?  Worsening; Any neural signs; If it factors into a decision re:
their work, sport, etc.; If they are not responding to treatment/affecting their ability to perform; Benefit to patient needs to
outweigh the risks of radiation
 If you find a segmental instability how should you treat it?  Stabilizing exs i.e. core/multifidus; NO mobs; Sometimes
braces are required for someone with an instability to be able to function in their work/daily life; Stability testing does not
stand alone, need the subjective (instability subjective = inconsistent, generally)
 At the end of the detailed assessment you know whether:
 The patient is appropriate for physiotherapy treatment
 And / or whether they need concurrent medical care (further investigations, medication for pain control)
 Severity and Irritability of the condition
o Irritability – refers to how easily symptoms are flared up and how long it takes for them to settle after flaring up.
Also note what kind of activity causes the flare up for example 10 minutes of skydiving is not the same as 10
minutes of standing!
o Severity – refers to pain scale, amount of medication, type of medication, effect that the pain has on ADL, lifestyle,
work, and leisure activities.
 Location and type of the mechanical problem
 Postural and ergonomic needs
 Treatment goals and likely time frame
 Repeatable, Measurable Outcome Measures to monitor progress

Low Back Pain: Clinical Presentation 'Patterns'

 Root signs = signs of nerve root compromise i.e. Loss of myotome, reflex or sensation
 Capsular pattern in the spine = painful, limited ipsilateral sideflexion, rotation and extension, full but painful flexion at the end
of range

Impairment Symptoms Signs

Disc Lesion LBP +/- Leg pain Non-capsular pattern
LBP +/- Root pain +/- Root signs
Aggravated by sitting, flexion, cough/sneeze +/- Dural signs ( SLR, Slump, FNS )
+ve torsion / compression
Spinal Stenosis (Older age group) LBP +/- Leg pain Capsular/ Non-capsular pattern
Aggravated by standing & walking, relieved +/- root & dural signs, may be more than 1
by sitting down (flexion) segment involved
Spondylolisthesis LBP +/- Leg pain ‘Step’ deformity
*Doesn’t go away, hopefully doesn’t Aggravated by prolonged standing, walking, +/- muscle changes
progress (core stabilization!) extension +ve stability test
Eased by flexion
Sacroiliac Dysfunction Buttock +/- Leg pain Local tenderness +/- +ve kinetic tests, +ve stress
Aggravated by turning, twisting, swing phase, tests (SI Joint)
in & out of car, weight bearing
Zygapophyseal Joint Dysfunction LBP +/- Leg pain Non-capsular pattern
Aggravated by extension (also maybe by +ve flex or ext quadrant
stretch) +ve PAVMs (specific to facet joint!)
Usually unilateral
Spondylosis DDD, DJD (older age LBP +/- Leg pain Often capsular pattern
group) (aka arthritis of spine) LBP +/- Root pain X-ray evidence of widespread degenerative
Stiff, worse when still, better with movement change
General Mechanical Dysfunction LBP +/- Leg pain Non-capsular pattern
Aggravated by mechanical forces, relieved by -ve for all of the above impairments
rest +/- postural imbalance
+/- muscle imbalance
+/- segmental dysfunction: restriction or
hypermobility
Chronic Pain Syndrome (> 6 Multiple chronic symptoms Non-specific signs
months) Behavioural changes Widespread guarding
*If pt presents with pain >6 months Failure of conservative treatment Non-organic signs
does not necessarily mean chronin Anxiety, depression, sleep disturbance
pain syndrome (need the anxiety
and other symptoms)

*Sliders/Gliders  don’t pull the rope through the door until you have opened the door or loosened the rope  need to first settle
down irritability  ALWAYS good to be cautious with neural issues  NEVER prescribe hamstrings stretches in a positive SLR
*Although traction is good for a lot of conditions, if asked to do a very specific movement (i.e. rotation) THEN NEED SPECIFIC TX
FOR OSCE
Manual Therapy Treatment of the Lumbar Spine
Objectives of Treatment
1. Pain modulation Grade I & II mobs, soft tissue techniques, electromodalities, thermomodalities
2. Mobility of joints -Purpose: Stimulate tissue to be laid down along appropriate lines of stress, enhance fluid dynamics and stimulate
and soft tissues afferent input to modulate pain, alter muscle reactivity, & provide proprioceptive input to the CNS
-Techniques: (choice of technique should be based on presenting signs/symps, impairment present, and healing stage
Manual = joint mobilization, soft tissue mobilization, massage, traction, manipulation, muscle energy techniques, friction
Mechanical = traction, bracing and external supports
Active = exercise protocols, concentric, eccentric, hold-relax, PNF
3. Biomechanical Give ppt skills for self-management, education about preventing reinjury and to provide optimum conditions for healing.
Counselling
4. Enhance -Optimal neuromuscular control, motor control exercises, proprioception.
Neuromuscular -Optimum stability, strength, flexibility, endurance, & cardiovascular conditioning
Performance -Positioning for optimum spinal posture

Principles of Treatment applied to the Spine: (same as for any other area in body)
 Treat according to findings on subjective and objective examination  For example, if the subjective exam indicates a highly
irritable condition, i.e. it does not take much to flare up the symptoms and it takes a while to settle them down, then
proceed with caution on your first treatment session.
 Treat according to the ‘end-feel’  Grade I and II mobilizations in the presence of pain, spasm or hypertonicity, grades III and
IV where there is resistance before pain
 Treatment time will also be dictated by joint irritability and stages of Healing
 Reassess frequently, during the treatment session and between treatment sessions. Reassess subjectively and objectively. Be
prepared to change your hypothesis if the patient is not responding as predicted

Outcome Measures
Impairment Measures Disability Outcome Measures
Pain: Functional Questionnaires: e.g. Oswestry, Roland-Morris
Visual analog pain scales / or Disability days, Employment status
Numeric Pain Scale Cost / Utilization - # of visits, charges for services
Analgesic intake Oswestry Disability Index: validated measure responsive to low back pain. It measures activity and
Duration or recurrence of pain participation restrictions within ICF classification, Patient fills in a Likert Scale (rated 0-5) on a 10-item
Pain Questionnaires questionnaire, it was originally designed for patients with chronic low back pain.
ROM: Schober test SLR Roland Morris questionnaire: 24 Item scale related to acute, subacute or chronic low back pain. Also a
Strength: validated measure responsive to LBP. It is easily understood by the patient and easy to administer and score.
Dynamometer measures Both ODI and Roland Morris are valid and reliable and appropriate measure of disability
Physical tests / Oxford Scale. secondary to low back pain. ODI may be more suitable for chronic pain.

Lumbar Spine Manual Therapy Treatment Techniques

Soft Tissue Specific Muscle Erector spinae, quadratus lumborum, iliopsoas, rectus femoris, adductors, hamstrings, hip rotators
Techniques Stretching
Lateral Flexion -Set-up: pt sidelying close to the edge of the table, hips and knees flexed and supported
(Sidebending) on the table, a small, soft roll may be placed under the lumbar region to encourage the
SF curve; pt lies on good side, treating side on top (may need pillow between legs for comfort esp
females w/ wide hips)
-Process: PT stands facing the patient, weave cranial arm through pt's top arm letting it contact the
shoulder girdle, caudal forearm over pt’s hip, fingertips sink into tight paraspinal musculature
Fingertips can contact the far sides of the spinous processes
for more articular effect
-Movement = press outward (ABD) and downward with forearms
 fingertips knead tight soft tissue as it is stretched into SF,
slowly and rhythmically or pull upward on the spinous processes
to create a more articular technique  hold until it releases 
add more stretch w/ pt’s top arm up overhead
*Useful for general soft tissue stretching (erector spinae), for
multisegmental tightness, to decrease a long SF curve (non-
structural scoliosis)
Lumbar Spine Manual Therapy Treatment Techniques
Passive General Rotation Grade 1&2 (Very gentle, generalized technique)
Physiological *Lie patient on -Set-up: pt lying on right side with pillows under head, close to edge of the
Movement side opposite to lying on point of shoulder, left arm resting on chest wall  Hips and knees
direction of flexed, top knee slightly in front of bottom knee tuck top foot in arch of bottom
rotation desired foot, area to be treated midway between flexion and extension (neutral)
eg - to gain left -Process: PT standing behind the patient, place hands on the pt's pelvis
rotation, lie on -Movement = hands push pelvis in the direction of the long axis of the femur
right side  Gentle rocking movement should take place - the top femur should glide
forward
*This technique
Grade 3&4
can also be done
-Set-up: pt side lying close to edge of bed, landmark interspinous processes just below TL junction, then pull
facing the patient
pt’s bottom arm through until junction locks  Maintain this by weaving PT arm through  PIVM up to bellow
if they feel
segment you want to treat by flexing hips, then extend pt’s bottom leg straight, top leg flexed to the level being
insecure about
treated and hooked over bottom leg
falling off the bed
-Process: PT facing the patient close to side of bed to
support pt in side lying  Cranial hand stabilizes pt's
shoulder back, other hand pulls patient's pelvis forward to
produce a rhythmical rocking movement in line with femur
(can palpate interspinous spaces, but not necessary)
*General mobilization and pain relief in cases of unilateral
back or leg pain.
*Can also produce lumbar rotation through the use of
unilateral P/A’s, and transverse pressures.
Passive Posteroanterior -Set-up: pt prone lying, arms relaxed by sides; PT contacts spinous process to be mobilized with the thumb
Accessory Central Vertebral pads of both hands or ulnar border of hand using other hand for support
Movement Pressure -Movement = segmental movement is produced by downward pressure. Movement is
initiated by the trunk, through the arms, forearms, into thumbs (graded oscillations are
used, I – IV)
*For pain relief and as a specific mobilization in the direction of flexion(angled slightly
cranially) extension (angled slightly caudally)
Posteroanterior -Set-up: pt prone lying, arms relaxed at sides; PT contacts TVPs to be mobilized with
Unilateral the thumb pads of both hands
Vertebral -Movement = segmental movement is produced by downward pressure through the
Pressure arms, forearms, to the thumbs (graded oscillations are used, I-IV)
*Movement obtained will be rotation in the direction opposite to the side of the P/A
pressure
*For pain relief, specific mobilization in the direction of rotation
Transverse -Set-up: prone lying, arms relaxed by sides (or can be done side-lying); PT contacts
Pressures side of spinous process to be mobilized with thumb pads of both hands
-Movement = segmental movement is produced by sideways pressure through arms,
forearms, to the thumbs (graded oscillations are used, I – IV)
*Movement obtained will be rotation in the direction opposite to the direction of the TVP
*For pain relief, specific mobilization in the direction of rotation

Traction -Set-up: pt crook lying, close to the end of the table; Hip and knee flexion to eliminate
the lumbar lordosis
-Process: PT stands, or kneels on bed at the end of the table, facing the patient 
Fingers interlaced on the posterior aspect of the patient's proximal calves (can also
place a belt behind the patients’ knees, and loop around the pelvis of the PT  lean
back to apply force)
-Movement = PT exerts a longitudinal pull along the long axis of the femurs, movement
can be graded  May use oscillatory motion or a more sustained pull
*Provides gentle traction to relieve compressive forces; provides gentle movement to
painful segments unable to tolerate more vigorous techniques; used to assess
suitability for mechanical traction
 Selection & Application of Manual Therapy Technique
Selection: Determined by palpation findings, PIVM, PAVM, quality, quantity of movement and endfeel, can also be determined by:
distribution (area) of pain
 By assessment findings (active, PIVM, PAVM):
o Determine segmental movement restriction and limiting factors (i.e. is it pain, spasm, resistance?)
o Choose a technique which will move the segment in the direction of the motion barrier  e.g. if L4/5 is limited in
the direction of flexion (as determined by PIVM and P/A testing), then a P/A on L4, angled slightly cranially could
be applied to restore flexion
o Determine grade of treatment by the end-feel (relative presence of pain, spasm, or resistance)  never mobilize
through a spasm end feel!
o Clinical Note: Sometimes techniques producing movement in direction of motion barrier can aggravate signs &
symptoms, conversely, techniques producing movement opposite to motion barrier can be more helpful 
Frequent reassessment (subjective + objective) is important to determine if technique is appropriate
 By distribution of pain: (STOP if pain peripheralizes or radiates!)
o Central pain: bilateral / symmetrical pain  P/A pressure on spinous process  Traction: General or specific
o Unilateral pain:
 P/A pressure on spinous process OR transverse pressure on spinous process
 P/A pressure on transverse process or zygapophyseal joint of involved side
 General rotation (painful side uppermost often most effective but not always)
 Traction: General or specific

Application:
 Determine whether you are treating PAIN (pain comes on before you get an end-feel or at the same time as you get an end-
feel) or RESISTANCE (tissue tension, capsular tightness, stiff joint, resistance comes on before pain or resistance is >pain)
and choose the appropriate grade of movement.
 IF TREATING PAIN: Perform the accessory movements with the joint in a painless position or use physiological movements
in a painless part of the range  Grades I – II are used to obtain a neurophysiological response
 IF TREATING RESISTANCE: Both accessory and physiological movements are performed AT THE LIMIT of available range 
Grades III – IV are used to obtain a more mechanical response, but there will also be a neurophysiological component
 Initially try 2-3 ‘sets’ of a technique (30-45 seconds each) of the appropriate grade.
o Reassess (ROM & pain) and repeat if appropriate e.g. PA L4-5 Grade III 10x3, reassess ROM and pain  If
improved, repeat (Grade III, 10 x 3), again reassess and repeat (total 90 reps in his example)
 Keep treatment under control by: frequent reassessment of signs and symptoms, precise recording and knowing the effects
of one treatment before adding another
 *Always monitor neurological signs (reflex, dermatome, myotome) and symptoms (centralisation, peripheralization)

Grades of Joint Movement

 Grade 1: a small amplitude movement performed early in the range
 Grade 2: a large amplitude movement performed early in the range (before resistance)
 Grade 3: a large amplitude movement performed to the end of the available range (into resistance)
 Grade 4: a small amplitude movement performed at the end of the
available range (into resistance)
 R1 = first resistance one feels, when the tissues start to tighten
 R2= limitation of range for example could be tight capsule.

Continuing Manual Therapy Treatment

Change in signs & symptoms Increase grade and/or duration of treatment
Improvement in signs & symptoms Continue w/ treatment
Patient is worse, signs & symptoms Stop, reassess, decrease grade and/or -Additionally, use ice or heat or appropriate modalities
duration -If any red flags or worsening neuro signs, refer to DR
Signs and improving, symptoms unchanged Continue treatment -Reassure pt, give additional advice on symptom
control i.e. ice/heat, joint positioning
** warn patients about treatment soreness and temporary after-effects
 If treatment soreness is enough to make assessment difficult, stop treatment for a day or two to allow soreness to settle
 NEVER push through spasm when it is protecting the joint you are treating
 Assessment During Treatment:
 First decide: Is a quick response expected or will progress be slow? (Refer to subjective history)  This is determined by
extent of trauma, longevity of condition, stages of healing, general health, previous trauma, structures injured.
 Reassess, using your chosen markers (subjectively and objectively) after each use of a technique during one treatment
session and prior to the next treatment
 The response to treatment is an important aspect of the constant re-evaluation of the hypothesis developed during the
initial assessment of the patient  Be prepared to reassess
 Be aware of factors other than treatment affecting the patient's progress  Ex) Patient continues to work or train hard
 Be aware of whether pain is centralizing or peripheralizing
 Signs and symptoms may not progress at the same rate

Therapeutic Exercise for Lumbopelvic Region: Mobility, Strength, Stability, CV conditioning, Neuromuscular Control, Specific
MOBILITY
Articular Mobility Restore articular mobility with graded mobilizations in the appropriate plane[s] of movement  Maintain the movement gained
with individual exercise prescription
-Lumbar spine flexion exs = knee to chest; bilateral/unilateral; 4-point position; symmetrical/asymmetrical
-Lumbar spine extension exs = prone press up; standing ext; 4-point ext; prone unilateral leg ext
-SIJ lesions (remember a lesion is named according to the position it is held in):
Anterior rotation lesion - hip flex will help to posteriorly rotate the innominate
Posterior rotation lesion - hip extension / lunge will help to anteriorly rotate the Innominate
Muscle Assess individual muscle length and treat accordingly  Assisted stretches, can be supplemented with home exercises  For
extensibility any pelvic lesions, ensure that the pelvis is stabilized for all stretches
-Commonly tight/shortened muscles + redmedial exs:
 Erector spinae = knee to chest/ 4-point sit back / over end of bed  Quadratus Lumborum = SF/ all 4s SF sit back
 Iliopsoas = lunge – at chair / kneel stand – control lumbar ext  Rectus Femoris = heel to buttock – side-lying/standing
 Short Hip ADD = side lunge / tailor sitting  Hamstrings = supine / active lengthening in sitting
 Piriformis = ADD at 90 / semi=crossed knee to chest / prone IR
Neuromeningeal Assess (slump, SLR, PKB) and treat per findings  Think about neuromeningeal mobility prior to stretching exercises
mobility

STRENGTH
 Trunk strength and endurance tend to be decreased in patients with LBP
 Multifidus atrophies very quickly following LBP and does not regain full bulk spontaneously with resolution of LBP  Those
trained in multifidus strengthening exercises had lower incidences of recurrence (Hides)
 In chronic LBP sufferers, the timing of the transversus contraction was also affected, delayed onset of recruitment was
noted
 When retraining trunk muscles, initially isolate muscle to be strengthened, then incorporate into more functional patterns
 Consider various parts of the range.
 Muscles that tend to weaken = Inner Unit (TA, multifidous, pelvic floor); diaphragm; rectus abdominis; external/internal
obliques; gluteus maximus, minimus, & medias (esp. posterior fibres); quads

STABILITY  Lumbar Instability

 Causes: consequence of the early stages of degeneration or can be following trauma to the ligs, capsule, disc or as a result
of muscle dysfunction (dynamic instability)
 Characteristic Symptoms:
o Recurring episodes of back pain causing temporary immobility
o Episode provoked by simple unguarded actions eg twisting
o Aggravating factors include prolonged positioning, better with moderate activity
 Signs:
-Visible ‘crease’ -Abnormal muscle activity -Painful arc during movt -+ve stress tests -Excessive motion on PIVM’s
-Movement ‘hinges’ around unstable segment -Excessive motion on P/A pressures with a boggy soft end-feel or muscle spasm
-Abnormal spinal motion during active movement = Catches, ‘Walk -X-Rays: Traction Spurs, Degenerative Disc Disease, Osteophytes
back up legs’, Kinks -Dynamic instability - lack of motor control (neutral zone particularly)
 When bony or articular stability is compromised muscular performance becomes even more important
 Motor control also a major factor
 Individualized exercise programs as being the most clinically effective in pain management and in decreased recurrences of
LBP.
  The trunk muscles are active (at a low tonic level) in a co-contraction pattern during functional activities such as gait,
bending, and lifting  To rehabilitate the stability function of these muscles, activities which promote the co-contraction
pattern should be used
 Principles:
o Isolate inner unit of core muscles
o Co-contraction [TA, multifidus, pelvic floor]
o Focus on neutral joint position – isometric initially
o Tonic Vs phasic activity - prolonged hold many reps throughout day
o Challenge by adding load or changing base
o Train inner core muscles
o Integrate limb motion while maintaining neutral spine
o Strengthen muscles of outer unit [anterior oblique sling, posterior oblique sling, lateral sling] while maintaining
inner unit control
o Maintain segmental spinal control (via inner unit) during lumbopelvic motion
o Stability at higher speeds

CARDIOVASCULAR CONDITIONING (Endurance)  Cardiovascular conditioning has been shown to be effective in pain management
for the LBP patient, examples could be exercise bike, fast walking, elliptical etc

NEUROMUSCULAR CONTROL (Motor Control)  Goal is to maintain optimum spinal efficiency in all positions and tasks and should
be part of any stability routine. Goal is also to maintain optimum recruitment and patterning of core muscles

WORK / SPORT/ ACTIVITY SPECIFIC

 Exercise Parameters  How much? How many? What position? Progressions *Individual prescription is the key

Additional Lumbar Spine treatments:

1) Mechanical Traction
 Mechanical traction is a useful adjunct to treatment and is used in the compression +ve patient with radicular symptoms,
especially where manual traction is helpful.
 Purpose is to obtain intervertebral disc separation and pain modulation
 Patient position will be governed by patient comfort and also which area in the lumbar spine you are trying to target  It
may be more useful to traction a patient prone for upper lumbar problems and supine for lower lumbar
 The knees can be supported at different degrees of flexion, again depending on which area you are trying to target
 It is a good idea to palpate the lumbar spine while the traction is on to ensure that you are getting the segmental separation
that you desire.
 Contraindications to lumbar traction = Acute / Patient is unable to tolerate position / Patient has bad response to manual
traction / Recent surgery / Underlying hyper mobility or instability / Vascular compromise
 Efficacy
o Weight = a greater increase in force does not appear to have a greater effect on pain
o The group most likely to benefit from it have radicular pain and neurological deficit with a duration of 6 weeks or
less..
o An increase in SLR has been demonstrated post traction
o Intervertebral separation does occur, greatest when the patient is supine with the knees flexed  occurs most at
healthy discs [!] and lasts longer in older patients [!]
o Forces required are only 10-20% body weight
o Traction may reduce pain via mechanical separation, relieving pressure on the nerve root or it may relieve pain via
mechanoreceptor effect  Both sustained and intermittent traction have a therapeutic effect, intermittent tends
to be more comfortable and safer initially.
o After traction, patient should reload spine gently by doing pelvic tilts or a few isometric contractions prior to
standing up
2) Spinal supports
 Lumbar spine supports have been shown to reduce the load on the lumbar spine by up to 1/3 and may decrease pain to
increase function
 They are recommended where there is an underlying instability and where muscular rehab alone is not controlling the
patients’ symptoms e.g. Retrolisthesis on x-ray with a physical job
 However, they may increase blood pressure so should not be used in susceptible individuals
 They may also be indicated post-surgery e.g. spinal fusion.
 PELVIC GIRDLE OVERVIEW & ASSESSMENT
Research in the Pelvis
 Use of clinical practice guidelines  new 2017 guideline
 Motion analysis  limited in pelvis, hard to quantify range at the joint
 Outcome measures
 Clustering of tests  great region for clustering (no one test that has perfect value
for diagnosis)

Stability of the pelvis

 The functional unit of the Pelvic Girdle consists of the 2 Innominates, the sacrum,
bilateral hip joints and L4/L5
 Biomechanics of the SI joint  The axis of motion is unknown. Many axes are proposed
 Arthrokinematics  These are unknown, small amounts of cranial / caudal, ventral / dorsal gliding occurs.
 Stability is provided by ‘form closure’ and ‘force closure’
 For optimal pelvic function a mixture of form and force closure is necessary = the Self-Locking mechanism of the Pelvis

Form Closure Force Closure

-Stable situation with closely fitting joint surfaces, where no extra forces are needed to -Extra forces may be needed to maintain pelvic stability
maintain the state of the system’ i.e. the passive system = Joint congruency and during loading situations i.e. ‘‘force closure”
ligamentous support  Ex) interosseous ligament, ventral and dorsal SI ligaments, -This is provided by muscles (active system)
sacrotuberous ligament, sacrospinous ligament and long -The most important muscles
dorsal ligament (posterior SI ligament) are those which cross
-In adult SIJ, stability provided by interlocking grooves and perpendicular to the joint
ridges [cartilage covered bone extensions protruding into the surfaces  Ex) glut max,
joints] and the wedge shape of the sacrum (form of joint) transversus abdominis AND
(Image = sacrum in centre, 2 innominates on either side) those w/ pelvic attachment
-Loss of form closure can commonly occur: during pregnancy/ -Loss of force closure: sedentary/de-conditioning,
post-partum due to ligament laxity (relaxin), fall on the buttock, trauma (see less of but abdominal sx (even if laparoscopic), pregnancy
more significant than loss of force closure)
(Where unknown, small
amounts of cranial / caudal,
ventral / dorsal gliding occurs)

 Total Range of Motion: Consider movement of the pelvis as a unit and intra-pelvic motion  Up to 4 degrees is proposed
and ankylosis is rare even in old age  Movement is necessary for shock absorption and to absorb torque force in
locomotion
o There is motion available (it is SO MINIMAL)
o To date no proof that we as manual therapists can quantify this ROM
o ome evidence to support asymmetrical movement as being a key factor in pain production from the SI joints
o Movement of the innominate: Anterior AND Posterior Rotation available
o Movement of the sacrum: Nutation AND Counternutation
 Nutation (Nod) = flexion of the sacrum in the Pelvic Bowl = sacral sulcus deepens  Nutation is the most
stable position for the SI joints and it tensions the sacrotuberous and sacrospinous ligaments
 Counternutation = extension of the sacrum, the sulcus is shallow and the sacral base tips backwards  It
is a relatively unstable position for the SI joints

Lesions of the Pelvis

 A ‘Lesion’ is always named after the position it is held in. e.g. An anterior innominate means that the innominate is held
anteriorly and cannot go posteriorly. It is only a lesion if there is a restriction on passive testing. If there is no restriction
then it is merely a positional fault. Compare with the opposite side.
 1) Lesions at the Pubic Symphysis
o The pubic bone can be held superior or inferior or even separate. Typically pubic lesions are peri-partum due to the
hormonal laxity and also to mechanical stresses in pregnancy, giving birth and shortly after birth.
o When seen in Men, it is often associated with herniations of the posterior abdominal wall caused by twisting,
turning and kicking sports e.g. soccer.
o For the purposes of this course we will be doing all treatments through the Innominate or sacrum but remember
they can have an effect on the symphysis as the pelvis is a stable ring.
 2) Innominate lesions
o The innominate can be held in either anterior rotation or posterior rotation due to muscle imbalance or loss of
form or force closure or both. E.g. The innominate can be held anteriorly due to a shortened quadricep and
lengthened, weakened hamstrings and / or loss of force closure. Refer to worksheet for findings
 3) Sacral lesions
o The sacrum can be held in nutation or counternutation due to loss of form or force closure or altered lumbosacral
function. Nutation is the most stable position for the sacrum. When treating the sacrum don’t forget it can have an
effect on the L5-S1 segment.
o A lesion is always named according to the position it is held in. If you can move it then it is merely a positional
fault not a lesion. THINK. What could cause a positional fault? Muscle imbalances, leg length (other biomechanical
adaptations), habitual postures/sports (twisting and sitting)
 Findings R anterior Innominate (EXAMPLE)
Positional tests -ASIS anterior + inferior
ASIS, iliac crest, PSIS -Iliac Crest angled anterioinferior
-PSIS anterior + superior
Active mobility tests -Won’t mobilize posteriorly very well
Kinetic test Ipsilateral -Ipsilateral, PSIS won’t rotate posterior + inferior
Contralateral -Contralateral, sacral movement may not occur (could get positive)
Forward bend test -Fwd bend test, right side will look higher
Passive physiological tests -Loss of movement anteriorly (held in this position)
Anterior/Posterior Rotation -Loss of ROM as cannot go posteriorly

Pelvic Girdle Pain Syndrome

 Loss of form closure  inflammatory arthritis, pregnancy, trauma
 Loss of force closure
 Differential diagnosis; Inflammatory conditions (AKS), systemic diseases (Reiters syndrome), Pelvic inflammatory disease,
visceral dysfunction, lumbar spine and hip dysfunction (Bear this in mind in the subjective interview)

Subjective Assessment of Pelvic Girdle

Onset Traumatic = fall, sports, MVA,
Insidious = loss of force closure, repetitive strain, pregnancy, peri-partum, muscle imbalance, post abdominal surgery,
biomechanical adaptation (i.e. post hip surgery or secondary to lumbar spine dysfunction), hormonal (cyclical behaviour?), AKS,
arthritis, lumbar spine referral
Location Local / unilateral, referred to the buttock, groin, posterior thigh, anteromedial thigh (innervation L3-S2), tenderness, particularly
over the posterior SI joint line (can get the patient to shade in areas of pain on body diagram)
Behaviour Aggravated by = side lying, rotation, getting in/out of car, heel-strike, worse with weightbearing through SI
Eased by = rest
Special Bladder / bowel dysfunction, perianal numbness, bilateral paraesthesia, anaesthesia, saddle paresthesia (cauda equina)
Questions Clicking and location (e.g. Pubic symphysis), feeling of giving way.
Usual Work and work ergonomics, sport, leisure activities, sleeping posture, pmhx, previous treatment and results.
Subjective Hx
Investigations & More likely to be treating child-bearing females for SIJ  x-ray not common due to radiation risks, bone scan (if suspect
Results inflammatory bone condition), MRI (RARE; used as constellation of tests)  Research shows that PTs are more effective at
diagnosing SIJ pain than imaging, only refer for imaging if suspect systemic
Objective Assessment of the Pelvic Girdle
*Always do lumbar scan to evaluate lumbar component and check the integrity of the neurological, vascular and musculoskeletal
systems
*For all tests assessing SIJ  landmark over PSIS and drop slightly inferiorly and keep this same bony landmark
 Observation
 Trunk movements
 Active mobility tests
 Kinetic Tests – ipsilateral and contralateral
o Looking for asymmetrical difference; normal to have some differences; compare side to side
o Ipsilateral  PSIS should go caudally or stay same
o Contralateral  Sacrum should go caudally or stay same
 Hip extension test, standing / prone  palpating over PSIS and sacrum, ipsilateral, looking for PSIS to go cranially
 FBT- standing / sitting
 Positional tests [also known as palpation tests] / looking for symmetry, compare with the opposite side and remember that
asymmetry in position is typical and means nothing but asymmetry of movement or passive tests is meaningful when
combined with subjective history and pain provocation tests. These landmark tests have no standalone value.
Supine Prone
ASIS Iliac Crest
AIIS PSIS
Pubic Ramus Ischial tuberosities
Pubic Symphysis Sacral sulcus (deep or shallow)
ILA (inferior lateral angle, deep or shallow)

 Passive Mobility tests / Compare side to side, looking for asymmetry. End Feel.
 Stability and pain provocation tests
Passive Physiological Movements  Note: Quality and quantity of movement available, AND end feel
Innominate Anterior & -Set-up: pt sidelying (side to be tested uppermost)  PT has one hand
Posterior Rotation (cupped) on the ASIS and the other hand on the posteroinferior aspect of the
joint (more up on the iliac crest posteriorly)
 For anterior rotation = PT hands on iliac crest, and ischial tuberosity (make
sure don’t get extension crease)
 Support lumbar spine with towel for female (pillow between legs if really
wide pelvis with small waist), make sure don’t flex legs too high (put too much
pressure through SI by tensing glutes); will feel more range posteriorly
-Process: gently posteriorly and anteriorly rotate the Innominate

Sacral Nutation/ -Set-up: pt prone

Counternutation -Nutation = PT palpates the sacral base (find PSIS, drop into
sacral sulcus, then medial onto sacral base i.e. top of sacrum)
and applies a ventral force to create nutation with heel of hand 
applies direct pressure to lumbosacral junction
-Counternutation = PT palpates the sacral apex (ILA) and apply a
ventral force with heel of hand to create counternutation 
patient often feels good when you do this (unload lumbosacral
junction)  can often get clicks and pops
 Muscle length and strength tests
 Pain Provocation / Stability Tests Clusters
For SI joint Pain  Pain in SIJ region For Symphysis Pubis Dysfunction  Local pain at pubic symphysis
1) Posterior Pelvic Pain Provocation test (P4 test), 1) Tenderness on palpation especially if it lasts >5 seconds after palpation.
2) Fabers test (pain must be in the SI joint region), 2) Modified Trendelenburg Test.
3) Gaenslen’s test and 3) Active SLR
4) Tenderness on palpation over the long dorsal ligament

For lumbopelvic Dysfunction / failed load transfer / Dynamic Stability Test

Active Straight leg raise test Ability to concentrically and eccentrically control active raising and lowering of a straight leg. Failed load transfer
indicated by subjective report of pain and / or difficulty coupled with objective note of trembling / pelvic rotation and
inability to control lumbopelvic region.
Active straight leg raise with Note difference from above with use of hands to mimic SI belt (may indicate temporary use of SI belt would be
force / form closure assist useful) and with use of transverse abdominis / pelvic floor contraction

Stability & Pain Provocation Tests

Look for asymmetry side to side. A positive test for SI / pubic symphysis pathology is indicated by local pain at the SI joint or pubic symphysis.
**Clinical note = many patients experience discomfort in the groin when the hip is flexed (does not mean a positive test for SI pathology)
P4 Test (Posterior -Process: Hip is flexed to 90° (can add a tiny bit of ABD and IR) and PT applies a posterior force to the
Pelvic Pain patient’s femur
Provocation test) -Positive = if the patient experiences pain in the SI region (If they have groin pain, then can back off a bit)
**Can be very provocative / Don’t push through patella, hug leg and apply force posteriorly.

Gaenslen’s Test -Process: One hip is maximally flexed while the other is extended over the side of the bed producing
intrapelvic torsion which can affect either SI joint (testing both sides when you do this)

Fabers Test Usual faber (not the quadrant faber), but positive test when included in SI cluster = pain reproduced at SI joint. Faber’s test when
used to detect SI pathology is positive if pain is experienced in the SI region.
Palpation At Pubic Symphysis and / or over the posterior SI ligament; joint line palpation (medial to the PSIS and palpate along joint line)
Cyriax Tests 1. Compression of the anterior joint  distraction of the posterior joint
2. Distraction of the anterior joint  compression of the posterior joint (sometimes get better findings when stabilize one side and
apply pressure to one side only)
*Note quality and quantity of movement, pain produced, end-feel
Modified -Process: Patient stands on one leg and palpates for asymmetry at the pubic symphysis and notes any local pain.
Trendelenburg (‘flamingo stand’ test)
Active SLR -Process: Ask pt to actively lift leg, compare R/L and see if there is any pain
-Positive = If see massive tilt, loss of control, pain/symptoms; if positive, repeat w/ form closure and force closure assist
 Form closure assist = therapist’s hands compressing the SIJ at the greater trochanter level / or try just below ASIS, trying to be
like a belt holding the pelvis together, no exact spot
Force closure assist = contraction of the pelvic floor, TA, obliques
*Clinical note, if the ASLR test is dramatically improved with form closure assist, then pt may benefit from wearing SI belt. If
improvement noted with force closure assist, then determine which muscles need to be rehabilitated + prescribe exs

Muscle Length and Strength Tests

 Determine from the assessment whether you are dealing with a problem of stiffness (hypomobility) or excessive movement
(hypermobility) and whether mobilisations are appropriate or not  Determine appropriate exercises to mobilise / stabilise
/ stretch or all of the above.
 Muscles that attach to the pelvis = biceps femoris, glutes, hip IRs, hip ERs, piriformis, iliopsoas, rectus femoris, TFL/IT band,
sartorius, adductors, abductors, quadratus lumborum (assess length in side-lying by applying pressure to innominate and
ribs), lats
 MANUAL THERAPY TREATMENT TECHNIQUE FOR THE PELVIC GIRDLE
1. Passive physiological mobilisations
2. Muscle energy techniques (Considered ‘active’ techniques, as the patient actively participates)
a. Not very specific  not actually specific unlike PAVMS
b. Often if we feel a stiffness or tightness in assessment, it is usually due to muscle tightness, altered tone etc. so it’s
okay that this is not very specific (normal actual SIJ movement = 3 degrees in each direction)
3. Muscle balance (stretching, recruitment and strengthening)
a. **Important to work on training pelvic floor muscles with SIJ problems, more functional to do pelvic floor exs in
sitting vs. supine  PTs highly effective in treating pelvic floor issues
Passive Physiological Mobilisation
Innominate **Perform exactly as per assessment techniques
(Anterior or -For treatment you can facilitate your technique by placing the patient’s hips in more flexion if you wish to
Posterior increase posterior rotation and more towards extension (watch for lumbar lordosis) to facilitate anterior rotation
Rotation) of the Innominate
-Try standing behind the patient to increase anterior rotation
-Grade the movement according to the patient’s presentation
**If it is too difficult for you to move the innominate, you can mobilize the sacrum instead
Sacrum **Nutation / counternutation done per assessment techniques  Grade appropriately
(Nutation or * Reassess subjective and objective clinical markers after each technique.
Counternutation -Nutation  posterior rotation of innominate (nutation is most stable position for pelvis, specific biomechanics
) are under review)  graded nutation = same handling (on sacral iliac junction)
-Counternutation  anterior rotation of innominate (easier if you don’t have patient on pillow, but have some
towels under the innominate, gives you something harder to push against)  same handling (on ILAs)

Muscle Energy Technique (MET) / Active mobilisation technique

 Definition: Manual Therapy procedure which involves the voluntary contraction of a patient’s muscle(s) in a precisely
controlled direction, at varying levels of intensity against a distinctly executed counterforce applied by the operator = hold
relax or contract relax technique  The patient actively participates in treatment and applies the corrective force (can be
used for any joint in the body)
 Indications for Use = Acute joint (as MET only takes the patient to R1 i.e. first barrier of resistance) and does not go to the
end of the range / Muscular resistance to the movement or muscular end-feel / Muscle imbalance / Muscle spasm /
Segmental stabilisation e.g. the spine / As a precursor to an articular mobilisation technique.
* An effective technique using MET can be very useful to treat SI joint dysfunction as many of the conditions we see may in fact be
related to muscle imbalance or altered muscle tone  very good at settling joint with spasm etc.
Technique for MET
-Set-up: Position pt appropriately
Anterior rotation of innominate = best to have the pt’s hips more towards extension (sidelying or prone)
Posterior rotation of Innominate = pt with the hips more flexed (but not too flexed....no more than 70°)
-Process:  Start with a series of isometric contractions  Choose the most effective contraction to achieve the desired result i.e. move
innominate in direction you are try to move it (recruiting the agonist or the antagonist = more common and more effective usually)
Should be local and GENTLE and PAINFREE for the patient
Duration 3-7 seconds, allow relaxation, passively take the joint to the new motion barrier and repeat as long as the technique is effective
Re-examine your chosen reassessment markers after 3 times
*White arrows represent suggested
isometric contractions and black arrows
represent the joint mobilisation in the above
photos BUT test each patient individually
and use whichever contraction helps
facilitate the joint moving in the direction
you want to treat it in

*MET is always appropriate in the pelvis (no

matter what the end-feel)
Additional treatment techniques for the Pelvic girdle:
 Stabilisation using form closure (belt  below ASIS)
 Stabilisation using force closure (muscle strengthening)
 Medical interventions such as prolotherapy of the long dorsal ligament (usually only indicated in extreme cases of
instability, recalcitrant to other forms of treatment)
o Prolotherapy creates a massive inflammatory response + pain relieving component  inflammation is
supposed to create a CT proliferation in order to stabilize the area (occurs up to 90 days after treatment)
 Electrotherapy as indicated
 Proprioception (be careful w/ single leg activities in those who are irritable in single leg stance)
 Referral (for someone with ongoing pelvic floor issues, if suspect rheumatological condition)
 Biomechanical counseling (esp. twisting)
 Address other joints  lumbar spin or hip

EVIDENCE BASED PRACTICE IN THE DIAGNOSIS OF PELVIC GIRDLE PAIN (PGP)

Outcome measures for PGP
 Pelvic Girdle Pain Questionnaire (Self report of 20 activity and 5 symptom items with 4 point scale response)
o SIJ usually responds very easily to treatment  if not seeing changes with treatment then important to investigate
inflammatory conditions
o SIJ pain characterized by pain with shearing forces (single leg stance type activities) and rolling over
 Disability rating index / patient specific functional scale / Oswestry
 Confirmation of PGP includes a cluster of tests. There is no single test with proven reliability in the diagnosis of PGP. Clinical
Practice Guidelines [CPG] are based upon multiple systematic reviews of the best available evidence in the diagnosis,
management and treatment of conditions.

Pelvic Girdle Pain in the Antepartum Population: Physical Therapy Clinical Practice Guidelines Linked to the International
Classification of Functioning, Disability, and Health. Clinton et al; Journal of Women’s Health Physical Therapy: May 2017 - Volume
41 - Issue 2 - p 102–125

Incidence Prior hx of pregnancy, and orthopaedic dysfunction, Increased BMI, history of smoking, job dissatisfaction and belief that
they won’t get better are considered risk factors. (Clinton et al 2017) The incidence/ point prevalence of pregnant women suffering
from PGP is about 20%. (Vleeming et al 2008) Subjects with asymmetric laxity of the SIJ during pregnancy have a threefold higher
risk for moderate to severe pelvic pain to persist into the postpartum period, compared to subjects with symmetric laxity during
pregnancy.

Recommendations for Clinical diagnosis: Firstly, rule out the lumbar spine or hip as a cause of pain as it can refer to the SI joint area.
The following cluster of tests is recommended. Subjectively; pain on prolonged sitting or standing, precise shading of pain areas on
diagram and additionally;
For SI joint Pain; Posterior Pelvic Pain Provocation test (P4 test), Fabers test (pain must be in the SI joint region), Gaenslen’s
test and tenderness on palpation over the long dorsal ligament,
For Symphysis Pubis Dysfunction; Tenderness on palpation especially if it lasts >5 seconds after palpation. Modified
Trendelenburg Test.

For all Mechanical Pelvic Issues (i.e. both SI joint and Pubic Symphysis) Dynamic Stability

Efficacy of Manual Diagnosis

Manual diagnosis is more effective than SI joint injection. MRIs are of limited value unless AKS or tumor is suspected. (Vleeming et al
2008)

Recommendations for treatment. Specific physiotherapy directed individualised exercises for the PGP population including water
based exercises for the pregnant woman. SI belts may be used for short periods of symptomatic relief where indicated.

Recommendations for future research: Comparison of exercise programs with and without the use of a pelvic belt, comparison of
individualized physical therapy with group treatment and comparison of cognitive interventions with exercise, effect of manual
therapy / manipulation treatment.