PHM301 Wednesday January 27th 2016

LUMBAR SPINE
Spinous Push Technique (Type IV fixation)
- Hypertonicity of the multifidous muscle
- Motion palpation patient seated, give themselves a hug, doctor stands on
the same side of palpation and rotates the patient towards you
o Normal movement of rotation SP moves away on R rotation, left
multifidus should be dominant, pulling the SP away
o Original and insertion goes from mammillary process of one
vertebrae obliquely to SP above
o A lot of these fixations occur bilaterally, so to treat that you will do
spinous push on both sides
o Unilateral fixation important to decide which muscle is causing the
problem
The side the SP turns to is the side with the problem
Position patient so that hypertonic multifidous is uppermost
put patient on their right if their left is fixated
- Make sure theyre not resting on their bottom shoulder and the headpiece is
elevated
o Bring leg up until you feel the SP move
o Stabilize the thoracic area put their arm up on the side of the thorax
then stabilize any of the 3 ways we mentioned e.g. deltoid, under the
patients arm and have them squeeze, or your whole forearm on their
arm
o Set-up looks like the spinous hook difference is your fingers are on
top of the SPs instead of under
Bend fingers when you contact the SP (so you can extend them
later on)
Palm of hand and forearm goes obliquely across buttocks
This technique is more effective if you go knee to knee instead
of thigh to thigh (more rotational power)
Have to take out joint slack before the thrust with knee, push
down towards the floor and the hand and forearm are pulling
pelvis and lumbar spine towards the doctor while the fingers are
pushing the opposite way (down towards the table)
Then do the body drop essential that the doctor comes down
close to the patient
- If patient is hyperflexible
o Move them further back on the table, that way the table will help
stabilize the patient more
o Trick #2 tuck the lower buttock under
- Direction of thrust of L4-5 is different thrust is more perpendicular
o L1-3 you have to radially deviate your wrist so the thrust is more
oblique
Iliomamillary push
- Lumbar equivalent of the iliotransverse stretch in the T spine
- If treating the right side, be on the left side of the patient

Pisiform contact on the mammillary process (which are fairly close to the SP)
o Push down with left hand (contact hand on the mammillary), pull up
with the right hand under the ASIS, hold and release as you move to
the different lumbar segments
o Here were just affecting the local muscles where in the iliotransverse
were affecting the erectors as well
o Prof usually uses this as a stretch technique before doing manipulation,
but can turn it into a manipulation though he finds its uncomfortable
for most people

Were done the lumbar spine from here. Next week we will be doing the sacro-iliac
spine, and then the week after will be review for the midterm.
LUMBAR SPINE REVIEW (because we had the time and the class wanted it)
Motion palpation for type II fixation
- Laterally flexing to the left, normal movement is SP coming towards the left
(towards you)
o Quadratus lumborum muscle is the dominant one here
o Type II fixation is picked up on lateral flexion SP will move away
(abnormal vertebral activity but normal disc activity)
Caused by erector spinous muscles on the other side (pulls the
SP over)
At least 90% of the time its a bilateral problem with type II
fixations
Lumbar roll (or specific) type II fixation
- Right pisiform contact on the mammillary process (above one interspace and
out about 2 fingerwidths)
- Make sure your fingers are on the same side as the side youre contacting
(dont cross the spine with your fingers)
- Usually we go thigh to thigh contact with this (could also do it knee to knee)
- Line of drive is directly across the patient doctors elbow has to wing out to
follow the line of drive (twist your body so youre looking at the patient so
your elbow will automatically come out)
Lumbar hook type II fixation
- Finger hook under the SP (were pulling it up), palm and hand and forearm go
obliquely across the buttocks
- More power if you go knee to knee with this technique
- This technique is also more protective of the doctors shoulder
Motion palpation for type III fixation
- Laterally flex patient, challenge the SP (should be soft and springy to be
normal)
- Normal vertebral activity but abnormal disc activity intertransversarius
muscle on the opposite side is in a spasm
- Technique to correct this will close the disc and stretch the intertransversarius
muscle at the same time
Closure technique type III fixation

No rotational thrusting, more of a lateral flex (soft tissue technique, not really
affecting joint capsule)
Move leg up until you feel the SP move set-up looks the same as lumbar
hook and roll
Position patient to produce a closing effect on the top side
o Hook medial aspect of elbow on ischial tuberosity, and other hand
hooks on top of the shoulder
Place fingers in between SPs youre working on (pointing down towards the
intertransversarius muscle)
Squeeze and release a couple of times, on the final one you do a body drop
(no twerking here)
To make it easier for yourself in office, can put a couple of pillows under the
patients leg and under their upper body