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/legacy-images/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 NWB- flexion 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_202_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

Any Questions?

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.