Distraction/Flexion Side-Posture Manipulation for the treatment of low-back pain and lumbopelvic dysfunction
Gray, David C
Distraction/Flexion Side-Posture Manipulation (DFSPM) is a nonoperative I method of treating mechanif cal low-back pain and dysfunction. It is clinically effective in the restoration of lumbopelvic function and the reduction of associated symptomatology.
It is our intent to advance and illustrate this concept and method for performing a unique side-posture manipulation that incorporates lumbar distraction and flexion, coupled with lateral flexion. This technique is clinically useful for mechanical dysfunction of the lumbopelvic spine and conditions with lumbar disc protrusion. When applied correctly, this manipulative chiropractic procedure has good patient tolerance even when significant muscle guarding and pain are present.
Additional studies incorporating blinded trials and other research methods need to be conducted to compare DFSPM with other nonsurgical treatment modalities.
Diversified side-posture manipulation
Antalgic Lateral Deviation (ALD)
Manipulation of the Lumbopelvic spine in the side-posture position was the paradigm of doctors of chiropractic for the better part of the 20th century.12 Although many other approaches were offered, including a variety of light pressure techniques, chiropractors tended to use the traditional side-posture methods when articular release and cavitation were desired.3 According to Cox, published articles in the 1970s raised the possibility of annular tear when using the traditional side-posture manipulation.4 During this period of debate, numerous seminars advanced assorted nontorsional light force and distraction techniques that claimed to avoid the dangers of the side-posture manipulation. Magnetic resonance imagery (MRI) and computerized axial tomography (CT) technology introduced in the late 1970s further explored the low-back pain epidemic. The pain led to spiraling health care costs and thousands of lost hours of productivity5-and a sharp upsurge in back schools and health clubs that capitalized on people’s fears. Disc failure and poor conditioning of back musculature were postulated as central to the etiology of low-back pain.6 Spinal disc surgery was performed on millions of Americans in the 1970s through the 1990s.7 Many chiropractors relegated side-posture manipulation to the treatment of minor back pain and segmental mobilization. New research in the last decade has demonstrated the presence of disc protrusion and herniation in asymptomatic individuals, perhaps downplaying a causal relationship between acute low-back pain and the presence of disc pathology.8
Side-posture manipulation has been unfairly judged. It can play a significant role in the management of low-back pain and lumbopelvic dysfunction. This paper describes a variation of side-posture manipulation that has safely been applied since 1955.
This technique was originally developed in the 1950s by Elmer Gray, DC, of Missoula, Montana, in an attempt to find a more effective treatment for low-back pain. His evaluation of lumbopelvic spine mechanics led to the development of a method of side-posture manipulation that places the lumbosacral spine in distraction and flexion pre-stress.
Concept of Distraction/Flexion Side-Posture Manipulation (DFSPM)
As a departure from traditional side-posture manipulation,9 DFSPM incorporates a method of patient positioning that allows the spine to move freely into antalgia. Beyond positioning, DFSPM uses a unique method of biomechanical analysis of the lumbopelvic spine.
It is traditionally taught that it is difficult, and even unwise, to manipulate a spine into guarded musculature.10 There are positions of comfort, however, in even very acute cases. Many acute low-back pain patients find comfort in the decubitus, or “fetal,” position. This position frequently includes flexion of the knees, hips, and lumbar spine, and is generally more comfortable on one side than the other. These observations led Dr. Elmer Gray to consider manipulating a patient in the decubitus position. Traditional side-posture diversified manipulation advocates extension of the down-side knee and some degree of lumbopelvic extension.10 Additionally, some techniques do not incorporate similar elements, including lumbopelvic flexion and bilateral knee flexion.11,12 DFSPM advocates flexion of both knees and hips, which results in lumbopelvic flexion. As a result, the lumbar or the lumbosacral articulation to be manipulated is flexed, thereby unloading the facet joints. During the setup and prior to the manipulation, the pelvis is caudally tractioned, which distracts and further unloads the facets. The manipulative line of drive is through the involved joint in a slightly inferior-to-superior direction, moving the joint into lateral flexion with the contact hand bridging the involved joint. Most important, the abdominal section of the table is set on spring load to allow partial movement and sag, thereby increasing the degree of lateral flexion to the involved joint. There is surprisingly little rotation, and this technique can be easily modified for sacroiliac manipulation.
A functional assessment must be made prior to the application of DFSPM, with close attention paid to the postural distortions and dynamics of the psoas major and erector spinae muscle groups. Failure to follow proper protocol greatly reduces the efficacy of this procedure.
Determining the specific level of mechanical joint dysfunction is beyond the scope of this paper, and it is assumed that the clinician has a skillful method of spinal analysis. The authors utilize standard examination procedures taught in chiropractic curriculum, including range-of-motion evaluation, motion palpation, radiograph and MRI findings, neurological correlation to spinal segmental levels, and clinical physical findings consistent with sensory and motor disturbances.
After the specific level of dysfunction has been identified, the existence of any postural distortions or reactive muscle patterns should be evaluated. This consideration is very straightforward in cases involving obvious postural antalgia. An excellent example is a patient with a left posterolateral disc protrusion, where the patient leans to the right, away from the pain (Figs. 1A and 1B). We call this postural distortion right antalgic lateral deviation (ALD). The right psoas is in a shortened, contracted state that bends the patient forward and laterally to the right. Consequently, the left erector spinae muscles attempt to stabilize the situation by going into a state of eccentric contraction. In treating this condition, it is imperative that the patient is placed on the treatment table left side down. The manipulation moves the spine into right lateral flexion. Because the maneuver does not elicit neuromuscular provocation, the adjustment is well tolerated, and deep cavitation usually occurs, which unlocks the fixated joint complex and restores function. Observable changes in postural mechanics are often immediate.
If there are no obvious neurologic or orthopedic indicators and ALD is not observable, the clinician must use more subtle signs and tests. The first of these tests is the standing leg raise. In this test, the leg is flexed at the hip while standing. The test can be performed with the knee extended or flexed, but the test is more sensitive if the knee is extended. Generally, if one side is taut and tender, guarded, or more difficult to flex, it is usually observed on the side of erector contraction and contralateral to the side of short psoas. This can be verified by bilateral palpation and observation of the tonicity of the erector spinae muscle groups with the patient lying prone. Hip joint pathology and hamstring tightness can also affect the standing leg raise and must be considered. The second test is a standing trunk flexion test. If the patient deviates laterally during trunk flexion, this frequently indicates psoas shortening on the side of deviation. However, it can also indicate the presence of a scoliotic lateral deviation, or chronic muscle imbalance.
In most patients, the side of erector spinous hypertonicity correlates to posterior vertebral body rotation that can be seen on an AP lumbar radiograph. The side of lumbar convexity (the open wedge side) is opposite the short psoas side for obvious biomechanical reasons. Some patients have anomalous lumbopelvic biomechanics, creating an exception to this rule. Scoliotic curvatures can also mimic acute and subacute postural antalgia, but are evaluated using the same protocol. We generally position the patient on the adjustment table with the side of erector hypertonicity, lumbar convexity, and posterior lumbar vertebral body rotation down. If there are conflicting indicators, the final test to verify if the patient is on the correct side is the degree of patient comfort during setup.
If the upper hip cannot be comfortably fLexed while in the side-posture position, the clinician should reevaluate. Improper patient positioning may trigger reactive spasms and patient discomfort, particularly in patients with acute and subacute pain.
Patient Positioning and Manipulation
Patient positioning is critical for effective DFSPM. For optimal success and reproducibility, the Zenith Hydraulic Utility Hylo model 210 (Williams Healthcare Systems, Elgin, IL, USA) is recommended, and the following steps are necessary. For this example, the position described will be for the purpose of manipulating a lumbar spine with a left posterolateral L4-5 disc protrusion (Figs. 1A and 1B). Examination and evaluation reveal that L4 and L5 are in left body rotation. The standing leg raise is positive on the left. The left erector spinae muscles are hypertonic, and the right psoas is contracted with respect to the left. The patient is instructed to stand on the table footpiece, facing the clinician, with his or her left side contacting the table (Fig. 2). The table’s pelvic cushion height is adjusted until it is level with the patient’s left iliac crest. The patient’s left arm is gently moved anteriorly, and the left hand is placed on the right anterior chest wall. The right hand rests comfortably on the abdomen. The head piece is elevated. The clinician lowers the table while supporting the patient and giving stability. During the lowering process, it is often helpful to slightly flex the patient’s hips and knees to increase comfort and improve balance. This should occur only after weight bearing is noticeably reduced. After the table is in the horizontal position, the patient’s knees and hips are flexed half way, with the upper leg flexed to approximately 90 degrees at the hip. At this point, the clinician distracts the lumbopelvic spine by tractioning the pelvis caudalward so that the left hip rests firmly on the pelvic cushion (Fig. 3). This tractioning should be performed by the clinician, not patient induced. The patient should be moved slightly toward the clinician at the time of caudalward tractioning. This combination of movement produces the flexion and distraction of the lumbar spine. The abdominal lock is released, and the tension should allow free movement of the abdominal cushion. While performing the setup and manipulation, the clinician stands on the right leg with the knee braced against the table edge and with the right hand resting on the anterior aspect of the patient’s shoulder. The clinician’s left leg rests lightly across the lateral aspect of the patient’s right knee and thigh. The clinician reaches over the patient with the left hand and establishes left pisiform contact on the second sacral segment, fingers directed cephalward. The hand is cupped to create the bridge across L4-5 (Fig. 4). The left hand pre-stresses the spine, increasing lateral flexion of the lumbopelvic spine while rolling the patient slightly toward the clinician. The patient is stabilized with the clinician’s right hand, which also assists in lateral flexion pre-stress of the spine. The patient is encouraged to relax and allow the clinician control Reassurance can be of benefit, as acute low-back pain will produce patient apprehension. This procedure should not be painful if the analysis and rules are followed. Timing in this procedure, as in all manipulation, is critical. The patient must willingly allow the procedure to advance. To test the patient’s willingness, it is often helpful to gently rock the involved joint complex in the direction of manipulation prior to the point of tissue resistance. If full patient cooperation is sensed, the manipulation may be performed.
The manipulation is performed by gently pre-stressing the L4-5 motion segment into right lateral flexion and minimal rotation with the left hand. This is immediately followed by a body drop through the right ileum, which results in further lateral flexion and cavitation of the L4-5 articulations. The manipulation thrust is not a force of the hand or body drop alone. Continuously increasing pressure is held on the patient’s thigh by the clinician’s thigh throughout the procedure. The body drop and leg pressure ensure that lumbar flexion is maintained throughout the manipulation (Fig. 5). When joint cavitation occurs (it usually does), a sense of deep articular movement is experienced. There is little or no discomfort when performed by the practiced clinician, and patients are often startled by the ease of movement. When the clinician is satisfied that adequate articular movement has occurred, the patient’s legs are gently extended, and the table is returned to the upright position as the patient is assisted to stand. The patient should be encouraged to ambulate immediately following the procedure to theoretically stimulate the mechanical receptors and continue to help restore normal biomechanical function.
Although we used an example for L4-5, all articular levels of the lumbar spine from the sacroiliac joint to L1 can be manipulated using this method. Sacroiliac joint manipulation incorporates hand contact bridging the appropriate sacroiliac joint with hip flexion at 90 degrees. Each ascending joint requires increasing hip flexion and shifting of the hand contact cephalward, bridging the joint to be manipulated. Manipulation of L1-2 would require hip flexion approximating 120 degrees and hand contact bridging L1-2.
This technique can be applied to all types of mechanical dysfunction of the lumbopelvic spine, including those cases resulting in mild-to-moderate disc protrusion. Contraindications include any condition involving neurologic deficits that result in loss of bladder or bowel function. Other contraindications may include cauda equina syndrome, bone infection, neoplasm, fracture, spinal stenosis, or certain surgical interventions.
DFSPM is an effective type of side-posture manipulation for acute or subacute mechanical low-back dysfunction, including mild-to-moderate disc herniation or protrusion. It differs from traditional side-posture manipulation because it adds the components of flexion, lateral flexion, and distraction to the procedure. It is useful for chronic low-back conditions and can be incorporated into treatment plans using maintenance or supportive care. It is comfortable for the patient and requires surprisingly less force than comparable side-posture adjusting techniques.
We are grateful to the intuitive insight of Dr. Elmer Gray for developing this technique and hope it makes a valuable addition to the chiropractic base of clinical knowledge. Additionally, we thank Dr. Thomas Bergmann for his insights and suggestions during the preparation of this manuscript.
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By David C. Gray, DC, and Patrick R. Montgomery, DC
Dr. Gray and Dr. Montgomery can be contacted at Health Options Clinic, 200 South Reserve St, Suite H1, Missoula, MT 59801, Telephone 406/549-4067, Fax 406/327-6702, E-mail email@example.com. Address correspondence and reprint requests to David C. Gray, DC.
Copyright American Chiropractic Association Oct 2003
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