Transcript Mechanical Low Back Pain and Muscle Energy

Mechanical Low Back Pain and
Muscle Energy Technique
Briana Baldino
VCU DPT 2016
What is Mechanical Back Pain?
• Misalignment or dysfunction of structures
within the spine
▫ Vertebral bodies, intervertebral discs,
zygapophysial joints, sacroiliac (SI) joints, spinal
ligaments, paraspinal muscles, dura, spinal cord,
and nerve roots
• Zygapophysial Joints
Review of Normal Mechanics
• Flexion: Open position
• Extension: Closed position
• Coupled motions: Rotation
and sidebending occur
ipsilateral when a segment
in is flexion or extension
http://www.spineuniverse.com/sites/default/files/legacyimages/facetjoints2_250-BB.jpg
Mechanical Examination
• Observe posture(standing and seated) and gait
for asymmetries
• Active range of motion
▫ Weightbearing and non-weightbearing
• Palpation of transverse processes, PSIS, ASIS,
sacral base, inferior lateral angle, and medial
malleoli
Assessing Lumbar Dysfunctions
• Assess the depth of the
transverse processes in NWBflexion in sitting and extension
in prone prop
• If a transverse process feels
more prominent/posterior, the
segment is rotated to that side
• Osteopathic texts also
advocate assessing segmental
tenderness, restricted ROM,
and altered tissue texture
http://perfectgolfswingreview.net/SpineLumbar.jpg
Positional Diagnosis
• If the rotation is found in seated flexion, it is an
ERS- the segment is stuck in Extension, Rotation,
and Sidebending
▫ The dysfunctional facet is on the side that the vertebra
has rotated towards
• If the rotation is found in prone prop extension, it is
an FRS- the segment is stuck in Flexion, Rotation,
and Sidebending
▫ The dysfunctional facet is on the side that the vertebra
has rotated away from
Sacral Dysfunctions
• Sacral dysfunctions always occur with a L5
dysfunction
• Palpate the sacral base and the inferior lateral
angles
▫ The SB and ILA on the same side will move
together- whichever side feels more prominent is
the side that the sacrum has rotated to
Sacral Dysfunctions
• Right on Right (ROR)/Left on Left(LOL)
torsions are always found with an ipsilateral
ERS at L5
▫ Found in trunk flexion
• Right on Left (ROL)/Left on Right (LOR)
torsions are always found with an ipsilateral FRS
at L5
▫ Found in trunk extension
MET Therapeutic Mechanisms
• Increase tissue extensibility
▫ Research has shown that it is more likely due to
increased tolerance to stretching rather than reflex
relaxation
• Influence pain mechanisms to promote hypoalgesia
▫ One theory is that it activates mechanoreceptors that
are involved with centrally mediated pathways
• Proposedly promotes changes in proprioception,
motor planning, and control
▫ Pain inhibits the deep stabilizers and the superficial
muscles overreact
Treatment
• Muscle energy techniques should facilitate
movement in the opposite direction of the
dysfunctional segment
▫ 3-5 seconds contractions repeated 3-5 times
• Monitor the movement barrier by palpating the
inferior and superior interspinous spaces of the
dysfunctional vertebra
MET for Lumbar ERS
• Position the patient in side lying on
the side that the vertebra has
rotated towards
• Add flexion until you feel the barrier
at the inferior space by flexing the
hips
• Add opposite rotation by rotating
the trunk away from you until you
feel the barrier at the superior space
• Add opposite side bending by lifting
the ankles until you feel the barrier
at the inferior space
• Have the patient push their ankles
down towards the ground
http://i.ytimg.com/vi/V6k2oyGGnXA/hqdefault.jpg
MET for Sacral ROR/LOL Dysfunctions
• Position the patient in side lying on the opposite
side than the sacrum has rotated towards
• Palpating the PSIS and SI joint, introduce
flexion, rotation, and side bending the same as
with lumbar ERS
• Have the patient push their ankle down into
your hand
MET for Lumbar FRS
• Seated or side lying
• Position the patient in side lying on
the side that the vertebra has rotated
towards
• Add extension until you feel the
barrier by pulling hips towards you
and pushing shoulders and legs away
• Add opposite rotation by rotating the
trunk away from you until you feel the
barrier at the superior space
• Add opposite side bending by lifting
the top leg until you feel the barrier at
the inferior space
• Have the patient pull their leg down
towards the ground
http://www.csuchico.edu/~sbarker/spine/spinealt/images/81.jpg
MET for Sacral ROL/LOR Torsions
• Position the patient in side
lying on the opposite side than
the sacrum has rotated
towards
• Palpating PSIS and SI joint,
introduce extension, side
bending, and rotation the
same as with lumbar FRS
• Flex the top leg and resist the
patient doing a clam shell
http://www.positivehealth.com/img/phfiles/Issue_202/Issue_2
02_Articles/cimg0239_(2).jpg
Now what?
• MET is just one tool- if the dysfunction occurred
secondary to poor mechanics or muscle
imbalances, its likely to reoccur
Interventions with Strong Evidence
• Manual therapy (soft tissue mobilizations, thrust
and non-thrust mobilizations, strain-counter strain,
etc)
• Trunk coordination, strengthening, and endurance
exercises
• Centralization and directional preference exercises
• Patient education
• Progressive fitness and endurance exercise
Sources
• Chien, J., & Bajwa, Z. (2008). What is mechanical back pain and how best to
treat it? Current Pain and Headache Reports, 12(6), 406-411.
• Day, J., McKeon, P., & Nitz, A. (2010). The efficacy of cervical/thoracic active
range of motion for detecting changes associated with individuals receiving
muscle energy techniques. Physical Therapy Reviews, 15(6), 453-461.
• Delitto, A., George, S., Van Dillen, L., Whitman, J., Sowa, G., Shekelle, P., . . .
Godges, J. (2012). Low back pain clinical practice guidelines linked to the
international classification of functioning, disability, and health.Journal of
Orthopaedic and Sports Physical Therapy, 42(4), A1-A57.
• Fryer, G. (2010). Muscle energy technique: An evidence-informed
approach. International Journal of Osteopathic Medicine, 14(1), 3-9.
• Licciardone, J., Minotti, D., Gatchel, R., Kearns, C., & Singh, K. (2013).
Osteopathic manual treatment and ultrasound therapy for chronic low back
pain. Annals of Family Medicine, 11(2), 122-129.