Chapter 1

LUMBO-PELVIC: Evaluation, Mobilization and Stabilization

I. History of Mobilization/Manipulation

A. Practiced since prehistoric times{3}
B. Known to Hippocrates and physicians of ancient Rome{3}
C. “Bone Setters” existed as long as there are records and still exist today{3}

II. Clinical Application of Mobilization

A. Activates joint mechanoreceptors (neurophysiological
effect) {19}

1. reduces pain {19}
2. reduces muscle tension {19}

B. Inhibits nociceptor activity {19}

C. Can be used to improve postural or kinesthetic awareness {19}

D. Improves joint mobility {19}

1. mechanical effect {19}
2. lengthens tissue (joint capsule, ligament) {19}

E. Improves muscle fluid stasis and accumulation of waste
products from metabolism {12}

1. increased nutrition {12}
2. reduces lactic acid buildup {1}

III. Receptor Systems

A. Joints have four varieties of receptor nerve endings
(mechanoreceptors) {19}

1. Type I
2. Type II
3. Type III
4. Type IV (nociceptors)

B. Type I mechanoreceptors

1. Located in the superficial layer of the fibrous joint capsule {19}
2. Characteristics {19}

a. static and dynamic
b. low threshold
c. slow adapting

3. Main functions {19}

a. a powerful tonic (continuous) regulation of the muscle tone around the joint
b. a contributing factor to the postural and kinesthetic reflexes

4. Respond to very small increments or decrements of tension when section of capsule in which they are located is being stretched or relaxed {1} 

C. Type II mechanoreceptors

1. Located in deep layers of joint capsule {19}
2. Characteristics {19}

a. dynamic
b. low threshold
c. rapidly adapting

3. Main function is phasic influence on the muscle tone around the joint {19}

4. Rapidly adapt to changes in joint position providing brief burst of activity at moment when tension increases {19}

D. Type III mechanoreceptors

1. Located in the peripheral joint ligaments {19}
2. No direct effect on the spine

E. Type IV nociceptors

1. Location {19}

a. entire thickness of fibrous joint capsule
b. articular fat pads
c. ligaments
d. walls of blood vessels

2. Characteristics {19}

a. nociceptive (free nerve ending)
b. high threshold
c. non—adapting

3. Main functions {19}

a. tonic reflexogenic effect on muscles
b. evoke pain
c. Type IV nociceptors

4. Sensitive to

a. noxious mechanical stimuli {13, 19}

(1) trauma {13}
(2) severe mechanical pressure {13}

b. chemical stimuli {13, 19}
c. extreme heat {13}

5. Remain inactive under normal conditions {19}

6. Mobilization in painful ROM could provide added stimulus to activate {19}

IV. The Functional Spine

A. The spine is required to take

1. compression (jumping) {20}
2. shear (pushing,pulling) {20}
3. torsion (twisting) {20}
4. tension (bending) {20}

B. The spine needs stiffness/stability for human functions {6, 20}, provided mostly by

1. discs {20}
2. ligaments {20}
3. vertebrae {20}
4. muscles {20}

V. Spinal Ligaments

A. Seven total {20}

1. anterior longitudinal
2. posterior longitudinal
3. intertransverse
4. capsular
5. ligamentum flavum
6. interspinous
7. supraspinous

B. The spinal ligaments function to

1. allow adequate physiological motion and fixed postural attitudes between vertebrae {20}
2. protect spinal cord by restricting motions within well defined limits {20}
3. protect the spinal cord where high loads are applied at fast speeds {20}

C. The ligamentum flavum

1. connects lamina above to one below {20}

2. highest percentage of elastic fibers of any tissue in the body {20}

3. in neutral spine

a. ligament strained 15% {20}
b. creates pre—tension for stability {20}

4. in full flexion

a. stretched {20}
b. 50% strain {20}

5. in full extension

a. contracted {20}
b. 5% strain {20}

6. ligament fails at about 70% strain (hyper-flexion) {20}

7. pre—tension diminishes with age {20}

D. The anterior and posterior longitudinal ligaments

1. also responsible for pre-tension {20}

2. only a fraction of the ligamentum flavum {20}

E. In ligament shortening resulting from scarring or poor posture {17}

1. added pre—tension and resistance during normal ROM {17}

2. may be an effect on normal ROM (reduction) {17}

3. may be secondary {17}

a. muscle hypertonicity
b. fatigue
c. pain

F. Ligament weakness/laxity

1. in injury, reduced tensile strength (medial collateral in knee returns to 50-70% tensile strength) {13}

2. reduced spinal rigidity/stability

3. symptoms

a. develop with activity {12}
b. increase during the day with activity {12}
c. dull, deep ache; muscle guarding; usually localized {12}

4. may be clinically instable requiring surgical stabilization

5. frequently overlooked

a. standard clinical examinations
b. x—rays, must be taken under

(1) compression
(2) traction
(3) stress

6. serious, chronic may lead to disc prolapse {12}

VI. The Muscles

A. General belief that muscles play role in stabilizing a spinal segent {12, 20, 22}

B. Segmental muscles considered stabilizers {4}

1. multifidus(transversospinalis) lumbar stabilizer {4, 12, 22}

2. erector spinae lumbar stabilizers {22}

3. rotators (best developed in thoracic) {4}

4. interspinales (best developed in cervical) {4}

5. intertransversarii (best developed in cervical) {4}

6. external oblique, internal oblique, transversus abdominis, and rectus abdominus. {13}

  Next: Chapter 2