Introduction to Met/MAP & manipulation

Introduction to Met/MAP & manipulation
Lumbar, Pelvis, & Sacrum

Objectives Compare and contrast MET/MAP to HVLA
Know the contraindications for HVLA Examine the differences between mobility, stability, & strength Palpate landmarks of the pelvis, lumbar, & sacrum Understand the biomechanics of the pelvis, lumbar, & sacrum Evaluate for pelvis, lumbar, & sacral dysfunctions Treat dysfunctions using MET/MAP for the pelvis, lumbar, & sacrum Practice treatment positions for HVLA manipulation of the pelvis, lumbar, & sacrum

What is Muscle Energy? Muscle Energy Technique or MET Active contraction of muscle provides mobilization of a joint Decrease firing of musculature using autogenic or reciprocal inhibition Purpose is to restore function of the joint Alternative to Manipulation (HVLA) Conservative Low Risk Treatment

MET/MAP MET is more correctly known as MAP or Myotatic Activation Procedure Contract a muscle to turn down the myotatic reflex so you can mobilize the joint What does this mean? Stop the over firing of a muscle through use of an inhibitory or reverse origin and insertion technique using the global system Why is this necessary? Muscle is in a protective range in attempt to create stability

Two types of MET/MAP Neuromuscular mechanical
Inhibitory to reduce firing of muscle to allow normal joint movement Autogenic – contract agonist to relax agonist Reciprocal – contract antagonist to relax agonist Isometric contraction of 6-8 seconds Reverse origin and insertion of muscle to apply a direct force to restricted segment Key is to use muscle attached to restricted segment Stronger contractions Isometric contraction of seconds

What is HVLA? HVLA = Grade V Joint Mobilization
Grade V - manipulation performed at a high velocity and low amplitude to the anatomical end point of a joint Treatment goals of mobilization Improve mobility Stretch contractile and non-contractile tissues Inhibit muscle tone or stretch reflex Improve joint proprioception Reduce Pain

HVLA Skill based technique requiring formal training
Useful tool for the right patient Ideal time for manipulation is ≥ 3 days post trauma i.e.: MVA-wait 3-4 days HVLA can be performed during acute phase for some mechanisms of injury i.e.: poor lifting Can you manipulate during pregnancy? 1st trimester – HVLA or MET/MAP 2nd/3rd trimesters –MET/MAP

Contraindications to HVLA
Absolute contraindications Relative contraindications Acute RA Fracture/dislocation Avascular necrosis Malignancy Acute myelopathy or Cauda Equina Syndrome Segmental spinal instability Aortic aneurysm Lack of diagnosis Patient can not tolerate Joint instability Hypermobility Bone demineralization Bleeding disorders or use of anti-coagulants Arteriole insufficiency Benign bone tumors Scoliosis Spondylolisthesis Feel

Myths of Joint Mobilization
Myth #1: “Bone out of Place” Not putting something back into place Out of place is a dislocation Myth #2: “Treat the painful side” Do not use pain as your diagnosis Dysfunction often on the opposite side of pain Pain is often an adaptation

Evaluate and Treat 1. Joint 2. Muscle 3. Nerve Mechanics
Hypermobility vs. Hypomobility 2. Muscle Stability vs. Instability Global Mobilizers vs. Global Stabilizers vs. Local Stabilizers 3. Nerve Neurophysiology Neurodynamics

Hypomobility vs. Hypermobility
Hypomobility – do not achieve physiological end-range Hypermobility – beyond the joints’ physiological end-range Hypomobility does not mean stability Often see hypomobility with instability (class focus) Hypermobility does not mean instability May see hypermobility with stability (rare)

Stability vs. Instability
Stability – control of joint neutral Instability - inability to control joint neutral Three Core Stability Categories: 1. Global mobilizers – fatiguing and fast i.e.: rectus abdominis, erector spinae, and latissimus dorsi 2. Global stabilizers – fatiguing & fast or non-fatiguing & slow i.e.: gluteus medius and external/internal obliques 3. Local stabilizers – non-fatiguing and slow; usually are not movement producing i.e.: transversus abdominis, multifidi, and vastus medialis oblique

Stability vs. Strength Stability and strength are not synonymous
May need to address both Strengthen using global mobilizers Stabilize using global or local stabilizers Do you need to stabilize or strengthen first? How does this relate to the joint? Articular restrictions create muscle imbalances Local muscle damage results in global muscle trying to take on role Muscle spasm and pain

Anterior View Pelvis ASIS and Iliac Crest

PSIS and Sacrotuberous Ligament
Posterior View Pelvis PSIS and Sacrotuberous Ligament

Pelvis Anterior View Quadratus Lumborum

Pelvis Posterior View Piriformis

Pelvic Palpation ASIS – palpate from multiple angles Iliac Crest @ L4
S2; palpate prone and sitting Sacrotuberous Ligament – medial to ischial tuberosity Quadratus Lumborum – Lumbar TP/12th rib to iliac crest Piriformis – between inferior lateral border of sacrum to greater trochanter (ER of hip with less than 60 degrees hip flexion; IR of hip with greater than 60 degrees)

Iliosacral Mechanics Sacroiliac joint (SI joint)
Movement of the ilium on the sacrum or movement of the innominate bones The innominate bone is formed by the fusion of the ilium, ischium, and pubis Movements include: Superior/Inferior Medial/Lateral Anterior/Posterior –rotation or shear

Iliosacral Dysfunctions
Anterior Rotation ASIS inferior/PSIS superior (small change) Little to no change with sacrotuberous ligament Posterior Rotation ASIS superior/PSIS inferior (small change) Upslip Superior ASIS , PSIS, Iliac Crest, & Ischial Tuberosity Sacrotuberous ligament is on slack

Posterior Ilial Glide Test
Objective test to determine hypomobile side Need patient in supine with therapist over patient Posteriormedial glide of SI joint Therapists’ elbows should be flexed ≈ 15° Test each SI joint separately Hypomobile side is the side of the dysfunction Treat the hypomobile side Hypomobile side may or may not be the side which is painful

Posterior Ilial Glide Test

MET/MAP for Anterior Rotation
I.e.: (+) R posterior glide test indicating a R Anterior Rotation Patient in L sidelying with R hip and knee flexed and supported on therapist Therapist places one hand on R ASIS and one on R ischial tuberosity Therapist rotates the R illium posteriorly into barrier Patient extends R hip against therapist for 6 seconds Repeat rotation followed by resisted R hip extension three times moving further into restriction each time

MET/MAP for Anterior Rotation
I.e.: R Anterior Rotation

HVLA for Anterior Rotation
I.e.: (+) L posterior glide test indicating a L Anterior Rotation Patient in supine with L hip and knee flexed Therapist IR and AD patient’s L hip Therapist grabs L L/E below knee Therapist distracts L L/E while patient exhales Therapist performs HVLA thrust inducing posterior rotation of illium Contraindication: ACL deficient knee

HVLA for Anterior Rotation
Ie: L Anterior Rotation

MET/MAP & HVLA for Posterior Rotation
I.e.: (+) L posterior glide test indicating a L Posterior Rotation Patient in supine with L leg off table Flex patient’s R knee and stabilize with hand Therapist adducts and IR rotates L hip Therapist grips L lower leg with adductors Patient exhales while therapist tractions L leg into the barrier; repeat x 3 HVLA: traction L leg during 1st exhale then perform thrust

MET/MAP & HVLA for Posterior Rotation
I.e.: L Posterior Rotation

MET/MAP & HVLA for Upslip
I.e.: (+) L posterior glide test indicating a L Upslip Patient in prone with L leg off table Therapist stabilizes R thigh with hand Therapist adducts and IR rotates L hip Therapist grips L lower leg with adductors Patient exhales while therapist tractions L leg into the barrier; repeat x 3 HVLA: traction L leg during 1st exhale then perform thrust

MET/MAP & HVLA for Upslip
I.e.: L Upslip

Quadratus Lumborum Stretch
Need to address QL with Upslip with self-stretch/HEP, MFR, or manual stretch using autogenic inhibition Directions for self stretch for HEP: Patient in sidelying with involved QL superior Patient flexes uninvolved weight bearing hip Patient raises upper arm above head Patient extends & adducts involved hip to stretch QL

Quadratus Lumborum HEP
I.e.: QL Self-Stretch for Upslip

Research and SI Joint Dr. Sturesson at North American Spine Society began research on the SI joint in 1985. Compared revelation to people learning the earth is “round”. Research showed that “hands on tests” or movement tests had poor reliability. There is no standard to compare tests against

SIJ Referral Pain Pattern
Approximately 10 cm caudally and 3 cm laterally from the PSIS1,2 13-27% of low back pain can be of origin from SIJ12

Movements of the Sacroiliac Joint
Goode et al3 conducted a literature review of studies assessing motion occurring in the SIJ with movement. 7 studies met inclusion criteria Found varying amounts of degrees of motion ranging from 0.5 – 8.0 degrees depending on the axis, in-vitro vs. in-vivo and which diagnostic imaging was used. Sturesson et al4 found up to 3.9 deg (mean of 2.5 deg) around the transverse axis and translation up to 1.6 mm (mean of 0.7 mm) using Radiostereometric Analysis (RSA) RSA considered gold standard for measuring movement of joints Compared to C-spine: Axial rotation induces up to 10.7 deg of sidebending at C4-C5, 9.2 deg at C5-C6, and 4.0 deg at C6-C714 Maximum of 1.3 mm at C4-C5 in a left-right translation

Examination of SIJ Freburger et al5 wrote commentary on the published evidence to guide examination of the SIJ. Potter & Rothstein6: pairs of therapists palpated levels of PSIS, ASIS, and iliac crests in standing and sitting in patients thought to have SIJ dysfunction. (n=17); poor intertester reliability with 35%-43% agreement between therapists. Assessed intertester reliability for movement tests including: sitting and standing hip flexion, supine long sitting, and prone knee flexion.

Examination of SIJ Cont’d (Freburger, 2001)
Laslett and Williams7: found high intertester reliability (64-82%) for measurements obtained with 5 of 7 pain provocation tests including: Iliac compression, iliac gapping, thigh thrust, sacral thrust, and Gaenslans. 3 out 5 postitive tests11: Sensitivity 91% Specificity 78% Jumps to 87% if symptoms can’t be centralized

Broadhurst and Bond8: 3 pain provocation tests (Patrick’s test, thigh thrust, and resisted hip AB) to identify subjects and assign groups. Double blind study using local anesthetic or normal saline (control). Patients rated pain intensity pre to post injection, and provocation tests were performed again. SIJ dysfunction was considered if there was a 70% reduction in pain with retest. Saline group: no meaningful decrease in pain. Local anesthetic group: majority had 70% or better improvement.

Tullberg et al9 used intraosseous markers and roentgen stereophotogrammetric analysis to assess if manipulation and mobilization affected SIJ position. No change in the position of the sacrum following intervention. Despite the lack of change using the analysis, most of the tests that were positive prior to intervention were determined negative post intervention. Conclusion: intervention was successful based on test-retest, however patient symptoms were not reported pre- or post.

Review of Research Cont’d
Sacroiliac Joint: an overview of its anatomy, function, and potential clinical implications (Vleeming ). A review of multiple studies (10) performed from 1978 – 2007 revealed SIJ mobility depends on positioning and loading however differences are reported in the amount of movement. Rotation of the sacrum around the transverse axis at S2 (nutation/counternutation) up to 4 degrees (mean of 2.5 deg).

SIJ Overview Cont’d (Vleeming10 2012)
“A dysfunctional SIJ is normally not related to a subluxated position of the joint, but to increased or decreased compression/force closure due to asymmetric forces acting on the joint.” Compression/force closure and increased SIJ stiffness can be attributed to the following: Isometric contractions of muscles that cross the pelvis ie: glute max, biceps femoris, and erector spinae. Stabilizing muscles ie: transversus abdominis and multifidus. Asymmetrical ligamentous laxity. Common theme amongst articles: Variability amongst reliability of palpation but agreement there is motion occurring.

What does evidence say? Can the SIJ be a source of pain?
Yes – confirmed with SIJ contrast provocation and anesthetic injections1,2 Is there motion in the SIJ? Yes – has been shown up to 8 deg nutation/counternutation in cadaveric studies but more commonly up to 4 deg in in-vivo studies3,4,10 Can we palpate it? Test it? High intertester rating with pain provocation tests7 Varying specificities and sensitivities of provocation testing although seems to be high when clustering tests5,6,7,10 Poor intertester reliability with palpation of motion tests5,6 SIJ training?9 Treatment? Neurotomy and Intra-articular injections– Limited and limited to moderate, respectively12 Little to no evidence of PT treatment. No studies with comparative randomized controlled trials of mobilization/manipulation/stabilization. Tullberg9 – mobilization/manipulation; Mooney et al13 - stabilization Is it subluxing? No9

Anterior and Lateral Views
Sacrum Anterior and Lateral Views

Sacrum Posterior View

Sacral Palpation Sacral Base or superior border of sacrum
Sacral Sulcus medial to PSIS Sacral Hiatus flattened area at inferior part of sacrum; located at S5 Inferior Lateral Angle (ILA) lateral to hiatus Palpate from inferior position Palpate from posterior position

Sacral Mechanics Type I mechanics: rotation and sidebending are opposite in neutral I.e.: if sacrum sidebends to the L, it will also rotate R Sacrum flexes (nutates) with lumbar extension and exhalation Sacrum extends (counter-nutation) with lumbar flexion and inhalation If contract the L piriformis sacrum rotates R If contract R piriformis sacrum rotates L

Axis of the Sacrum Oblique Axis Mid-Transverse Axis Mid-Sagital Axis
Torsions Named by base they originate from ie: Left Oblique Axis (LOA) or Right Oblique Axis (ROA) Mid-Transverse Axis Flexion or Extension Mid-Sagital Axis Sidebending

Sacral Dysfunctions Sidebent Sacrum Sacral Torsions Flexed Sacrum
Extended Sacrum I.e.: (L or R) Flexed or Extended Sacrum SIJ Dysfunctions Acute Forward Torsion (FST) Backward Torsion (BST) I.e.: (L or R) Forward or Backwards Torsion Piriformis or L5/S1 Chronic or Acute

Sidebent Sacrum or Torsion
Seated flexion test differentiates between two Patient flexes in sitting with supported lower extremities while therapist palpates both PSIS PSIS that moves more in a superior direction is the hypomobile side Asymmetrical movement of PSIS → sidebent sacrum Symmetrical movement of PSIS → sacral torsion

Seated Flexion Test

Sidebent Sacrum Flexed Sacrum Extended Sacrum I.e.: L Flexed Sacrum
(+) L sitting flexion test Deep L sacral sulcus Inferior L ILA Explanation: L sidebent sacrum with R rotation; L side is flexed; R side is extended; (+) test on L → L Flexed Sacrum I.e.: R Extended Sacrum (+) R sitting flexion test Deep L sacral sulcus Inferior L ILA Explanation: L sidebent sacrum with R rotation; L side is flexed; R side is extended; (+) test on R → R Extended Sacrum

MET/MAP for Flexed Sacrum
I.e.: L Flexed Sacrum Patient in prone; therapist on dysfunction side I.e.: L Abduct and IR the L hip; gaps the posterior SIJ allowing sacrum to move into extension Therapist puts R pisiform on L ILA and pushes superiorly while L pisiform is on R sacral sulcus pushing inferiorly Therapist applies force three times while patient breathes in (trying to induce sacral extension which occurs with inspiration)

MET/MAP for Flexed Sacrum
I.e.: L Flexed Sacrum

HVLA for Flexed Sacrum I.e.: L Flexed Sacrum
Patient in R sidelying with therapist in front of patient and L side or dysfunctional side up Rotate L patient using U/E and flex L hip forward Therapist palpates the L inferior ILA while straddling L L/E and holding patient at elbows Rotate patients’ L hip until sacrum faces ceiling (L/E may reach floor) ASIS of therapist against ischial tuberosity of patient Take up slack during exhalation Therapist thrusts hip and drops while driving inferior ILA in a superior direction

HVLA for Flexed Sacrum I.e.: L Flexed Sacrum

MET/MAP for Extended Sacrum
I.e.: R Extended Sacrum Patient in prone on elbows positioning & therapist on opposite side of the dysfunction side I.e.: L Abduct and ER the R hip; gaps the anterior SIJ allowing sacrum to move into flexion Therapist stabilizes R iliac crest with R hand, and applies anterior force at R sacral sulcus with L hand. Therapist applies force three times while patient breathes out (trying to induce sacral flexion which occurs with exhalation)

MET/MAP for Extended Sacrum
I.e.: R Extended Sacrum

HVLA for Extended Sacrum
I.e.: L Extended Sacrum Patient in R sidelying with therapist in front of patient and L side or dysfunctional side up Rotate L patient using U/E and flex L hip forward Therapist palpates the L sacral sulcus while straddling L L/E and holding patient at elbows Rotate patients’ L hip until sacrum faces ceiling (L/E may reach floor) ASIS of therapist against ischial tuberosity of patient Take up slack while patient exhales Therapist thrusts hip and drops while driving in perpendicular direction inducing sacral flexion

HVLA for Extended Sacrum
I.e.: L Extended Sacrum

FST or BST Special Test to differentiate between the two
Patient in prone Palpate sacral sulci – note positions Patient moves from prone to prone on elbows In extension both sulcus depth even → FST In extension sulcus depth uneven → BST

Prone to Prone on Elbows
Differentiates between FST and BST

FST vs. BST Forward Sacral Torsion Backward sacral torsion I.e.: L FST
Base of sacrum forward Deep R sacral sulcus and posterior L ILA in prone = depth of sulci with extension Explanation: sacrum flexes with lumbar extension; L side of base will and does flex forward; evens out sulci I.e.: L BST Base of sacrum backwards Deep R sacral sulcus and posterior L ILA ↑ R sulci depth with extension Explanation: L - L5/S1 facet will not flex with extension but R facet will flex ; R sulcus appears deeper

MET/MAP Treatment for FST
I.e.: Left Forward Sacral Torsion (FST) Dysfunction is with R piriformis Lie patient on R side (dysfunction side down) Rotate upper body to the L to level of L5 Flex both hips < 60° (keeps piriformis as a hip ER) Lift both legs inducing ER of R hip and IR of L hip Resist patient pulling legs to floor, inducing ER of the L hip ER of L hip inhibits R piriformis Perform 3 x for 6 seconds each while moving further into restriction

MET/MAP for Forward Sacral Torsion
I.e.: L FST

HVLA Treatment for FST I.e.: Left Forward Sacral Torsion (FST)
Dysfunction is with R piriformis Lie patient on R side (dysfunction side down) Induce L rotation and extend bottom leg (do not lock bottom leg into extension; more flexion) Flex the L hip forward and hook using bottom leg (sacrum not facing ceiling as in sidebent sacrum) Therapist palpates L posterior ILA and line of drive determined from position of forearm (must use posterior ILA b/c can not manipulate piriformis) Therapist takes up slack while patient exhales Therapist performs HVLA with drop (not hip thrust)

HVLA for Forward Sacral Torsion
I.e.: L FST

Piriformis Stretch Need to address piriformis with FST with stretch using uninvolved piriformis or quadratus lumborum (reciprocal inhibition) Directions for stretch using QL: Patient supine; therapist holds involved L/E Hip flexed > 60°; piriformis is now hip IR Knee in midline & hold ankle stretching into hip ER Patient using QL to hike hip → relax x 3 times

I.e.: R piriformis stretch for L FST

MET/MAP Treatment for BST
I.e.: Left Backwards Sacral Torsion (BST) Lie patient with restricted L L5/S1 up Therapist induces L rotation to L5 Extend bottom leg to S1 to induce sacral flexion Flex the L hip off table to gap L L5/S1 joint Resist patient lifting L leg superiorly Perform 3 times for 6 seconds each time with patient relaxing in between and therapist moving patient into restriction

MET/MAP for Backwards Sacral Torsion
I.e.: L BST

HVLA Treatment for BST I.e.: Left Backwards Sacral Torsion (BST)
Lie patient with restricted L L5/S1 up Induce L rotation until feel movement at sulcus Extend bottom leg to S1 to induce sacral flexion Flex the L hip to gap L L5/S1; hook with bottom leg (sacrum not facing ceiling as in sidebent sacrum) Therapist palpates L sacral sulcus and line of drive determined from position of forearm Therapist takes up slack while patient exhales Therapist performs HVLA with drop (not hip thrust)

HVLA for Backwards Sacral Torsion
I.e.: L BST

Anterior, Lateral, and Posterior Views
Vertebral Column Anterior, Lateral, and Posterior Views

Posterior and Lateral Views
Lumbar Vertebrae Posterior and Lateral Views

Lumbar Vertebrae Superior View

Lumbar Palpation Spinous Processes L1 through L5
Iliac crests and over to L4 spinous process Transverse Processes of L1 through L5 TP are 1-2 thumb widths lateral to spinous processes TP of L5 are superior and approximately 30 degrees medial to PSIS

Lumbar Mechanics Laws of Vertebral Motion: Type I Dysfunctions:
SB and rotation are opposite in neutral SB and rotation are same in flexion and extension Motion taken up in one plane; all other motions ↓ Motion lost to dysfunction ; all other motions adapt Type I Dysfunctions: In neutral with SB and rotation opposite Multi-segmental and adaptive I.e.: OA joint, T1-L5, and Sacrum Type II Dysfunctions: In flexion/extension with SB and rotation same Single segmental and traumatic Ie: C2-C7 and T1-L5

Lumbar Dysfunctions I.e.: FRSL Positional Dx:
Positional Dx: Motion Restriction: Restricted Facet: Posterior TP: FRSL ERSR Right Left FRSR ERSL Left Right ERSL FRSR Left Left ERSR FRSL Right Right I.e.: FRSL Positional Dx: Rotation is named by direction of the vertebral body Segment is in a position which is flexed, rotated and sidebent L Motion is restricted in extension, rotation and sidebending R Restricted facet on R More posterior TP on L

ERS or FRS Dysfunction ERS dysfunction FRS Dysfunction
Type II Dysfunction Name dysfunction by the positional Dx I.e.: ERSL or ERSR Found in flexion Feel for ↑ posterior TP I.e.: posterior R TP = positional Dx of ERSR and motion restriction of FRSL Position and treat into motion restriction = FRSL Type II Dysfunction Name dysfunction by the positional Dx I.e.: FRSL or FRSR Found in extension Feel for ↑ posterior TP I.e.: posterior R TP = positional Dx of FRSR and motion restriction of ERSL Position and treat into motion restriction = ERSL

Evaluation for ERS Dysfunction

MET/MAP for ERS Dysfunction
I.e.: Positional Dx ERSR L4 Found in lumbar flexion with R posterior TP Restricted facet is on the R Motion restriction = treatment position of FRSL Patient in R sidelying (L side up); therapist in front Rotate patient L from top to L4/L5 SP gap Flex patient from bottom to L4/L3 SP gap Lift leg(s) off table inducing L SB Resist patient pushing down with leg(s) for 6 sec Repeat x 3

MET/MAP for ERS Dysfunction
I.e.: Positional Dx: ERSR L4

HVLA for ERS Dysfunction (Long Arm)
I.e.: Positional Dx ERSR L4 Found in lumbar flexion with R posterior TP Restricted facet is on the R Motion restriction = treatment position of FRSL Patient in R sidelying (L side up); therapist in front Rotate patient L from top to L4/L5 SP gap Flex patient from bottom to L4/L3 SP gap Cross patient’s arms with bottom arm over top Therapist elbows and L hip/knee Therapist performs HVLA by pushing ↓ on L L/E during exhalation; induces L rotation and L4

HVLA for ERS Dysfunction (Long Arm)

HVLA for ERS Dysfunction (Short Arm)
I.e.: Positional Dx ERSR L4 Found in lumbar flexion with R posterior TP Restricted facet is on the R Motion restriction = treatment position of FRSL Patient in R sidelying (L side up); therapist in front Rotate patient L from top to L4/L5 SP gap Flex patient from bottom to L4/L3 SP gap Therapist stabilizes at elbows or weaves arm through patient’s elbows Therapist torso and across L hip/buttock Therapist performs HVLA driving towards self/floor during exhalation; induces L rotation and L4

HVLA for ERS Dysfunction (Short Arm)

Evaluation for FRS Dysfunction

MET/MAP for FRS Dysfunction
I.e.: Positional Dx FRSR L4 Found in lumbar extension with R posterior TP Restricted facet is on the L Motion restriction = treatment position of ERSL Patient in R sidelying (L side up); therapist in front Rotate patient L from top down to L4/L5 SP gap Extend patient from bottom up to L4/L3 SP gap Lift leg off table inducing L SB Resist patient pushing down with leg(s) for 6 sec Repeat x 3

MET/MAP for FRS Dysfunction
I.e.: Positional Dx: FRSR L4

HVLA for FRS Dysfunction (Long Arm)
I.e.: Positional Dx FRSR L4 Found in lumbar extension with R posterior TP Restricted facet is on the L Motion restriction = treatment position of ERSL Patient in R sidelying (L side up); therapist in front Rotate patient L from top down to L4/L5 SP gap Extend patient from bottom up to L4/L3 SP gap Cross patient’s arms with bottom arm over top Therapist elbows and L hip/knee Therapist performs HVLA by pushing ↓ on L L/E during exhalation; induces L rotation and L4

HVLA for FRS Dysfunction (Long Arm)

HVLA for FRS Dysfunction (Short Arm)
I.e.: Positional Dx FRSR L4 Found in lumbar extension with R posterior TP Restricted facet is on the L Motion restriction = treatment position of ERSL Patient in R sidelying (L side up); therapist in front Rotate patient L from top to L4/L5 SP gap Extend patient from bottom to L4/L3 SP gap Therapist stabilizes at elbows or weaves arm through patient’s elbows Therapist torso and across L hip/buttock Therapist performs HVLA driving towards self/floor during exhalation; induces L rotation and L4

HVLA for FRS Dysfunction (Short Arm)

Bibliography Emerson P 2004 MET: of the Lumbar, Pelvis, and Sacrum, Denver. Emerson P 2005 High Velocity Low Amplitude Manipulation, Denver. Schofield A K 2006 Core Stability Training: The Performance Matrix, Denver. Pluemer J. Joint Mobilization, and Overview of Maitland Techniques. Manual Therapy Netter, Frank H., Atlas of Human Anatomy-Second Edition, Novartis, 1997. Moore, Keith L., Clinically Oriented Anatomy-Fourth Edition, Williams & Wilkins, 1999. Richardson, Jan K., Clinical Orthopedic Physical Therapy, W.B. Saunders Company, 1994. Smith, Laura K., Brunnstrom’s Clinical Kinesiology-Fifth Edition, F.A. Davis Company, 1996. Bernhardt A. SIJ Movement. In-service

Bibliography Cont’d 1Fortin JD, Dwyer AP, West S, Pier J. Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part I: Asymptomatic volunteers. Spine 1994; 19(13): 2Fortin JD, Aprill CN, Ponthieux B, Pier J. Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part II: Clinical Evaluation. Spine 1994; 19(13): 3Goode A, Hegedus E, Sizer P, Brismee J, Linberg A, Cook C. Three- Dimensional Movements of the Sacroiliac Joint: A Systematic Review of the Literature and Assessment of Clinical Utility. J Man Manip Ther ;16(1):25-38. 4Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints: A roentgnen stereophotogrammetric analysis. Spine.1989; 14:162–165. 5Freburger JK, Riddle DL. Using published evidence to guide the examination of the sacroiliac joint region. Phys Ther. 2001; 81:l 6Potter NA, Rothstein JM. Intertester reliability for selected clinical tests of the sacroiliac joint. Phys Ther. 1985; 65: 7Laslett M, Williams M. The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine. 1994; 19:1243.-I249.

Bibliography Cont’d 8Broadhurst NA, Bond MJ. Pain provocation tests for the assessment of sacroiliac joint dysfunction. J Spinal Disord. 1998; 9Tullberg T, Blomberg S, Branth B ,Johnsson R. Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis. Spine. 1998; 23: 10Vleeming A, Schuenke M, Masi A, Carreiro J, Danneels L, Willard F. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat. 2012; 221(6): 11Laslett M. Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint. J Man Manip Ther. 2008; 16(3): 12Hansen H, McKenzie-Brown AM, Cohen S, Swicegood J, Colson J, Manchikanti L. Sacroiliac Joint Interventions: A Systematic Review. Pain Physician. 2007; 10: 13Mooney V, Pozos R, Vleeming A, Gulick J, Swenski D. Exercise Treatment for Sacroiliac Pain. Orthopedics. 2001; 24(1): 14McDonald C, Bachison C, Chang V, Bartol S, Bey M. Three-dimensional dynamic in vivo motion of the cervical spine: assessment of measurement accuracy and preliminary findings. Spine. 2010; 10:

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