Lumbar Mobilization Posterior to Anterior (Unilateral PA and Central PA)

Lumbar Mobilization Posterior to Anterior (Unilateral PA and Central PA)

This is Brent of the Brookbush Institute, and
in this video we’re going to go over a joint based manual therapy technique. If
you’re watching this video I’m assuming you’re watching it for educational
purposes, and that you are a licensed professional with joint based techniques
within your scope. That means osteopaths, chiropractors, physical therapists you’re
probably all in the clear. Physical therapy assistants, athletic trainers,
massage therapist you need to check with your governing body in your state
or region to see whether this is within your scope of practice. Personal trainers
this is definitely not within your scope of practice. Of course all professions
could use this video for purely educational purposes, to help with
learning biomechanics, anatomy and of course palpation. In this video we’re
going to do posterior to anterior mobilizations for the lumbar spine.
That’s both unilateral and a central PA’s. I think you are going to find all
of the spine that unilateral PA’s or UPA’s, are the workhorse for our
mobilizations of the spine. You’re going to use those possibly the most frequently.
I’m going to have my friend Melissa come out, she’s going to help me demonstrate. The
first thing we’re going to talk about of course is position. So I’m going to have
Melissa lie prone. If Melissa had pain in extension
I could put a bolster underneath her hips, just to give us a little bit of
flexion and me a little bit more room to be able to do these PA’s, without pushing
her into a painful range. You guys will notice her arms are in a relaxed
position, and we have these really nice tables at Flex here in New York, and
they have the arm drop downs. But if you didn’t have those, this position is
probably fine as long as somebody doesn’t have a really tight shoulder
girdle. Or you can have their arms by their sides. The thing you want to keep
away from is somebody putting their arms up, creating a lot of tension through the
latissimus dorsi because their latissimus dorsi does cross their lumbar spine. So tension here could make your mobilizations a little tougher.
The other thing, you can go ahead and put your arms down, arm cradle, the
other thing you want to consider is that Melissa needs to be low enough on this
table, that I can get my chest over her spine. So that when my arms are straight,
all I have to do is rock my torso to get my mobilizations. So in essence I’m using
my body weight, the weight of my torso to do my joint mobilizations
and not my hands, like trying to do something like this. Alright I see
people do that every once in a while, oh my gosh you’re going to wear out your hands.
Or they start trying to tricep press down their mobilizations, I
think you’re going to find it not only wears you out, it’s almost impossible on
bigger patients for the lumbar spine because the lumbar spine is pretty
strong and stiff to begin with, and I think you also find that your forces
aren’t very consistent. So if you’re trying to do these nice consistent
oscillations at the same depth, with the same resistance so that you’re
consistent and reliable, you’re going to have a hard time doing this, as opposed
to and then just rocking with your bodyweight. So the table is nice and low,
Melissa’s in good relaxed position. The next thing you guys probably want to do
as a newer manual therapists, new to mobilizations which I’m assuming you
are kind of for these videos. You probably don’t want to start by trying
to palpate through clothing. Now obviously we don’t want to move clothing
that people are uncomfortable with, but I can tell you adding a layer of clothing
is just one more layer of stuff that we have to try to feel through, and if we’re
talking about pants, right like if you have to try to feel through denim pants
forget it. Especially the L4, L5, L5 S1. And if you’re doing SI joint
mobilizations, trying to do those joints which are already very strong through
denim, is going to wear your hands out real quick. So what I’m going to do is have
Melissa lift her shirt up just above the bottom of her rib cage, because by
definition her lumbar spine would be below her rib cage right. So the 12th rib,
our last rib hooks into our last thoracic vertebrae and everything below
that is lumbar spine. And then I’m going to have her flip the top of her waistband
down. So she doesn’t have to like pull down her pants, she just needs to flip her
waistband down a little bit. And you know if you have people come in workout
clothes, sometimes these yoga pants do come up kind of high on females so be aware of that and don’t let that mess with your palpation. Make sure that
you find the top of their iliac crests, and that you can kind of get your thumbs
down to the sacral base, even if it’s just tucking just under the lip
of their pants, that’s okay. But you definitely need them to be enough out of
the way that you can get to the lumbar spine without having to push through
clothing. So the next thing we should probably think about is anatomy. Now if
you haven’t looked at the lumbar spine in a little while, you don’t remember how the
spinous process and transverse process, and where the facet joint is located, and
what muscles to work around, I definitely suggest a little review. You could start
with some of those soft tissue videos we did. The static release videos we did.
Maybe look at some of the anatomy of some of the muscles around the lumbar
spine, and I’ve mentioned in our other spine videos buying one of these plaster
cast spines is really an invaluable tool. And I understand that this spine is not
the same as Melissa’s spine and that the proportions are not identical, but you
take a huge step forward in testing yourself with a plaster cast spine on
let’s say, okay I’m going to find my sacral base, and being able to look
down and see if you’re on the sacral base. Then you can test yourself, okay I
want to get on to L4-L5. So I’m going to go L5 spinous process, L4
spinous process, fall off just lateral and inferior, and sure enough I’m on L4-L5, and I can look down. What you’re doing when you do that is you’re
starting to create a visual model up here, which is going to help you match to
what’s underneath the soft tissue here. If you don’t do that it just takes a
little bit more time, because this is essentially that with mush on top.
Mush being all the soft tissues right, and all these these lumbar extensors and
multifidi, and you got things like your quadratus lumborum which
are off to the side. And like if you’re not really kind of familiar and you
haven’t been doing a lot of manual techniques, it’s nice to have that thing
just to kind of to check things out. Now let’s talk about some of our first
palpations here. If I find the bottom of my rib cage, and follow those ribs up
and just follow that, they kind of come at an angle like this, and so I’m going to
follow that angle up to that spinous process, and then I go down one, that’s L1.
So L1, L2 and I can feel a little like the spinous process of very flat
tops. So what you’re going to feel is like flat and then there’s a little divot, and
then that’s the next spinous process and then a little divot, the next spinous
process. So once you find L1 you can go okay
L2, L3, L4 and hopefully what you’ll do is if you test yourself, you’ll get to the
sacrum which starts to feel like a crocodile’s back. It has like two ridges
essentially and it’s like bumpier it’s not so flat with a divot, flat with
a divot, it’s not that consistent anymore, it’s just bumpier down here right that’s
that’s sacrum. Hopefully you get to L5 and then sacrum and you’re not like L6,
L7, there’s there’s no L6 on most people. Every once – while you meet somebody
with an L6, but that’s a pretty rare thing to come across. So count your
lumbar vertebra, and then maybe the next thing you want to try doing is finding
the transverse process. Believe it or not the lumbar vertebrae are wide, they’re
like really wide. The transverse process are wide as your fist. So you can
get in here like this and I can feel like that’s bone out there, all
the way out there, and I’ll show you guys this in the close-up recap. It’s
they’re wide they’re really wide and feel it, you can get like L3, after L3
transverse process now that we’re on. You kind of run into the the iliac crest
here, and then they start getting hidden. So find the transverse process, find the
spinous process, and then the next challenge would be
to try to get your fingers on the facets, and the facets are going to feel
like bumps, a little more than a finger width from the spinous process. So if
this is my spinous process, I want to go a finger width over, and then
if we’re going this way the facet joint that’s related to the
spinous process that you were just on is actually lateral and inferior just a
little bit, just it’s just a tiny tiny bit. Once I am over the top of them, then what I want you to do is gently start trying to feel
through all the soft tissue and see if you can get that joint to move a little
bit. It does take a bit of force, it does take quite a bit of force. This is one of
those things where having a mentor who’s done this before is a really good thing,
because I think people get scared pushing on the spine and there’s reason
to be scared. Obviously we don’t want to damage anything, we don’t want to hurt
anybody. But to give you guys an idea if I’m doing a central PA I have to push
Melissa pretty hard into the table, like I’m using quite a bit of my body weight
to get to the end range of those facets that are associated with the L1 segment.
How does that feel? Yeah it’s a significant amount of pressure. So let’s
let’s talk about central PA’s now that we kind of know transverse process, we know
spinous process, we know round about where those facet joints are. Let’s start
moving down and kind of talking about these different mobilizations. So you
could do your central, what’s called a central PA on the spinous process with
two thumbs. You just kind of come to either side and do it this
way. I don’t like to do that and I’ll tell you why, anytime I can find a technique that doesn’t require my thumbs I use that technique, because there are
techniques where your thumbs are your only option and your thumbs will wear
out if that’s all you ever use. So a lot of therapists get themselves into
trouble because their IP’s of their thumb, they start ending up with
hyperextension, they can’t really get stable and it starts causing them a lot
of pain in that joint. So for this one I like what’s called a pisiform hamate or
cradle, I think it’s called a cradle saddle, saddle grip maybe is the right
term. What I do is I put this part of my hand right about where your
pisiform is, over the spinous process. Now that’s pretty comfortable for the
patient too because I’m pretty much just pushing them into the soft tissue
of my hyper thenar eminence there right, like the the mush underneath my pinky
finger. And then to use both of my hands, I’m going to take this hand and it’s going to
saddle over the top of my hand like so, and now when I get into position I can
just use my bodyweight. So you guys see that, this is what I’m
pushing with, but this is where my force is coming from, straighten out both my
arms and now I can do my central PA’s. Now I have to admit usually central PA’s I
don’t use unless somebody is super, super stiff. I more use these as as part of
my passive accessory motion exams where I go okay please tell me the difference
between pressure and pain, and I’ll push down and what’s that pressure or
your symptoms? That’s symptoms, okay so that’s symptoms and then I
started moving down. Pressure or symptoms? Pressure, pressure, pressure, pressure. Good
so we know in her case or at least we’re going to take a guess in her case that most
of her pain is coming through that thoracolumbar junction, somewhere like
the L1’s. So I’m going to want to start thinking
about what dysfunction happens there. Unfortunately hypermobility is actually
a more common at that segment, but the next thing to do would be okay do I feel
like that segment was hypermobile or hypo-mobile. The only way you’re going to
know that is from experience, and you do have to keep in mind that our patient is
probably our least reliable assessment. So this is one of those situations where
I may do mobilizations and then immediately retest. Just mobilize that
one one segment for 30 to 60 seconds, have them get up and see if I can
reproduce their pain. If they got better than we’re on the right track, if they
didn’t then maybe the segment is hyper- mobile we need to start thinking more
towards stabilization exercise. So again in central PA’s just thenar eminence
over like this, and then I use this like this, and then I’m going to push down to end
range if I’m doing an exam, and see where pain comes from. But if I was doing
mobilizations you know that it’s 50%. Alright so first resistance barrier,
end of arthrokinematic range which is there for her, back off to 50 percent,
and then I can either do my grade 3 by backing back off to the first resistance
bearing and pushing down to 50%. So that’s my larger amplitude, but less
intense mobilization because I’m backing all the way off to essentially no
resistance. Or I can get a little bit more intense by going right up to 50% or
maybe even a little deeper, and staying there with small amplitude mobilizations.
All right then see how that feels, and she actually does feel kind of stiff. So
I might try this and then see how she does, and you guys can follow this
technique all the way down. So what I’ll do is if I’m trying to do more segments
in the spine, test and then I put my two fingers like that right. So my pisiform
hamate is under the spinous process, I just take my two fingers, find the next
one down, move, and go two fingers down, go two fingers down, go and you can see I
can address the whole spine real quick there. Now let’s go back to the work
course technique of UPA’s. A lot of lumbar spine issues tend to be
asymmetrical. You have restriction on rotation to one side, or at least one
side is more restricted than the other, or lateral flexion is more restricted to
one side than the other, we start looking towards these unilateral posterior to
anterior mobilizations, this is why I’m going to have to use like a thumb over
thumb technique. So I’m going to find spinous process. Now we know in her
case her symptoms seem to be coming from somewhere around the L1 segment. So
maybe I start with L1-L2 facet. Push down, find the first resistance barrier, find
the end. How are you feeling? m-hmm mm-hmm, yep that’s that’s a little bit of her
symptoms. Alright and then maybe I start my grade three mobilizations, assuming
that it’s hypo-mobility right, despite the fact that she has pain there it’s
not pain, I don’t run into pain before I run into her mobility issues. It’s like
as I get to the end of her range she starts having pain, which tends to be
stiffness dominance if you’re talking about like a Maitland approach. So what I
might do is do 10 or 15 seconds worth of this, and then ask Melissa does that feel
like it’s getting better or getting worse? Okay so if it’s getting better
then I’ll keep doing it and then of course retest. I could go up,
the mobilization technique here is the same for T11-T12, T10-T11 like
it’s the same unilateral PA so I could go up a couple segments. I could go down
a couple segments, I could try the other side. Of course I would walk to the other
side of the table, but again notice that all I had to keep in mind was my anatomy
which is this facet is just lateral and inferior, if I’m talking L1-L2. If I
wanted to go T12 L1 then I have to go lateral and up just a tiny bit. I’m
keeping thumb over thumb so that I’m using both thumbs and I have as much
strength in my hands as I possibly can. My arms are practically straight and I’m
just using the weight of my torso to do the mobilization for me, keeping my
protocols in mind. Notice I’m not doing this, I’m not doing this, right that’s all
really bad technique. In fact for some individuals if you wanted to try
this, you could use the hand position we used on the static release videos, which
is dummy thumb in between our inner thenar groove applying the force. On some
individuals you might be able to get your hands into the right position, to
not have to use thumb thumbs at all in a straight up-and-down position,
you’re essentially using this as a little point that you’re then pressing
into with this; and sometimes that’s a little bit more comfortable for individuals. You could try maybe a little less specific going off to the
side and pressing on the transverse process with the pisiform hamate grip,
that we just talked about with the saddle grip. Keep all this stuff in mind,
although it’s not as specific as this, and I know some of you guys are thinking
well why wouldn’t I just use the best technique. The truth of the matter is, is
you’re going to get tired and if your thumb’s hurt, and it’s the end of a long
day, and you’ve had a lot of big individuals on your table, or a lot of
stiff patients. Or maybe it’s the end of a long week. Maybe you happen to be the
athletic trainer or physical therapist for like a football team, and everybody
you treat is just a really large human being.
Keep these other techniques in mind, a good technique is better than nothing.
Even if it’s not, don’t let perfect be the enemy of the good is
essentially what I’m trying to say. Let me show you guys just a couple more
things here, just some special palpations to keep in mind. If you find at the top
of the iliac crest right, and you keep following down you’ll eventually run
into the PSIS. If you find the space that’s kind of between the top of
the posterior iliac spine, the PSIS and then these spinous process here right.
What we’re on, this is L4 and L5. You guys will be
able to feel this a lot better than I’m showing it to you, but there’s like a
little place in between all of this bone mass that you start running into here,
and in there is your L4-L5 facet. It is definitely worth testing that facet. People forget about that facet. People will do all of this stuff because
it’s easy to access, and then they’ll kind of forget that they need to get in
there and really search for that facet specifically. How does that feel? That
feels really stiff to me. So you know she doesn’t have pain, but maybe she’s
getting hyper-mobile healer because this is super stiff, I would check on it. Now
the same thing with L5-S1. So find that triangular space, that’s kind of between
PSIS, the top of the posterior iliac crest, and the spinous process that’s
just lateral to it. Find that space and then what I want you guys to do is find
the sacral base, and I want you to keep feeling up the sacral base until you
fall off it and that’s L5-S1. And now I realize L5-S1 you might have to
go a little bit this way, to get that to move the way you want it to move. Again
these are worth checking. They are the two segments most likely to be
hypermobile, but they also have a propensity to become hypo-mobile. It just
depends on the condition, it’s a 50-50 shot. So if you feel like you got normal
or more motion than normal when you press into them, then leave them alone
because you can definitely make somebody worse by making them more hyper-mobile.
But I don’t know that I would ever rely completely on central PA’s without at
least checking L5-S1, L4-L5 facet, just to make sure everything is in good
working order. Alright so stay tuned for the close-up recap. Okay for our
close-up recap we have the lumbar spine, you can see how it’s nice and
visible here. The first thing that we talked about finding was maybe L1 right.
We did that by following the last rib up to the spinous process of T12,
because the last rib would hook into our last thoracic vertebrae and the next
spinous process we feel. Alright so kind of flattish spinous process divot.
Spinous process would be our first lumbar spinous process, and then we
started by talking about central PA’s which you know I told you guys could use
your thumbs like so. Alright I put one on either side, don’t press down on a
spinous process like that, that’s very pokey. But if you go this way
on just either side of the spinous process, you can notice there’s a
little bit of skin there in the middle. You could do it that way although that’s
tougher on your thumbs than you need to be. I would go ahead and put your
pisiform hamate spot, right this mush of hyper thenar meat right here, right over
the top of the spinous process and then you can saddle it up like this, and then
you get just that nice lean with your chest over top of where you’re trying to
mobilize, and you can just use your body weight. Real easy, and of course once we
found one spinous process it’s real easy to go okay spinous process divot, next
spinous process, spinous process divot next spinous process, spinous process
divot next spinous process. And keep in mind guys the spinous process takes up a lot more space than the tiny little divot in between spinous
processes. Now the next thing we talked about finding was your your transverse
process, which believe it or not come out about yay wide, they’re really wide. Like
this is me rocking Melissa’s lumbar vertebra
here, and you can see my hands are, they’re a fair amount apart like they’re her
fist width, not quite my fist width but her fist width apart.
Nice big lumbar vertebra with nice wide transverse process, and we can use
transverse process to do UPA’S. That is something that you’re going to want to
consider, especially if your thumbs start getting tired and you need to switch to
something like this position, this tends to work a little bit better using a
transverse process than trying to like get into a facet joint; because once you
guys are looking for a facet joints right, and you’re falling off that
spinous process about a fingers width away you’ll feel that bump, you can go
this way a little bit and feel a bump. You pretty much have to use your thumbs
to fit in there, otherwise this becomes tough. You end up getting multiple
segments, not that that’s a bad thing providing they’re stiff at all those
segments, but this is a bit more specific. All right so we have spinous process, we
have transverse process that come all the way out here, and then we could go to
facets in here and I’m going to show you this on the other side, although I’m on
the opposite side of this individual wouldn’t do these mobilizations this way.
So spinous process, transverse process is all the way out here, and then the facet is about right there. Alright so I hope that helps you guys with your
proportions a little bit. Now I did show you a couple special techniques. You know
we have the top of the iliac crest here. In line with the top of the iliac crest
is like the spinous process of L3-L4. If you go just below the spinous process of L4, so you kind of draw a triangle between that spinous process, the top of the back of the iliac crest here there’s like this little
triangle section that’s like leading into the bony sacroiliac joint, and the
bony PSIS. This little spot of still soft tissue, at the
bottom of that is the facet of L4-L5. I would keep that in mind because that’s
one of those segments that people forget to palpate. They’re palpating down, palpating down, palpating down, and then they stop because they either
accidentally hit the iliac crest, maybe they were too wide to begin with and
they were pressing on transverse process instead of facets. Alright so
they get to the iliac crest and they stop. Keep that L4-L5 facet in mind,
and then the other thing I want you guys to do is make sure that you find the
sacral base, which you know you’re going to come off the the flat sacrum, and then
just fall off the top of it so that you find L5-S1. Now those are the two joints
most likely to become hypermobile, but in a lot of individuals with a
chronic history of lumbar pathology they can also get stiff. So knowing how to
palpate and then mobilize L4-L5, and L5 and S1 are important
techniques to have in your arsenal. Of course the technique that we use is
the same as all of the other vertebral UPA’s that we’ve done. Once you find that
facet, find the first resistance barrier and then find the end of arthrokinematic
range, and you’re going to have to press down pretty good in the lumbar spine.
This is one of those techniques that having a good mentor will definitely
give you the confidence to push this to end range, and you’ll back off to 50%
between, and then you can do your grade fours right there at 50%, or you can back
off to zero resistance and go to 50% like a grade three. And of course make
sure you follow through your protocols getting a increase in joint mobility
before you stop, probably 30 seconds or more. So there you have it
assess, address, reassess. Make sure that every time you choose a joint based
manual therapy technique it is based on an assessment, and that you return to
that assessment after you’ve finished the intervention to see if it was
effective for the individual, the patient or client that you have in front
of you. Ensure that you continue to learn your Anatomy because your Anatomy is
going to help you with your hand placement, with understanding what a
joint can do, with understanding what you may gain from this particular technique;
and of course practice, you have to practice these techniques hopefully not
for the first time on a patient or client who just walked in the door. If
you can find a more senior instructor or a mentor to give you some really good
hands-on instruction, use your peers for some good feedback, and of course always
look for live education to help with your manual therapy techniques. I know
these videos make education very convenient but there is no substitute
for learning manual therapy in a live setting. I look forward to talking to you
guys again soon.

11 Replies to “Lumbar Mobilization Posterior to Anterior (Unilateral PA and Central PA)”

  1. I just want to follow you around for about a month haha… My spine teacher was brilliant but couldn't share his knowledge effectively like you can.

  2. Wauw. This is everything a good video needs, usually i have to steal info from 5 different videos to get the answers i need, but this is like and 5in1. 🙂 Good job!

  3. Oh, if my teacher would be like this , then I should not now study all YouTube for mobilisation technics ))))

  4. Wow! You are very good. I need to watch all your videos so I can better my manual therapy.
    PT from Zambia 🇿🇲

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