Evaluation and Treatment of Vertebral Motion
Segment Dysfunction
(Functional Assessment & Treatment of Spine related dysfunction)
Impaired or altered function of
related components of the somatic (body framework) system; skeletal,
arthrodial, and myofascial structures; and related vascular, lymphatic, and
neural elements is termed somatic dysfunction (International Classification of Diseases
– Hospital Adaptation, ed. 2, 1973).
Somatic dysfunction can be produced
by trauma or acquired as compensation for dysfunction elsewhere in the system.
Vertebral somatic dysfunction is
identified through an assessment of motion quantity/quality and tissue texture
at the involved vertebral segment. The quantity of motion at the dysfunctional
segment can be reduced (hypomobility) or increased (hypermobility) in relation
to motion at a normal vertebral segment. The end-feel during motion testing
provides qualitative insight into the nature of the barrier that limits motion.
Another qualitative measure of vertebral motion is its symmetry. The
asymmetrical motion of the component parts of the vertebral segment, when
symmetrical motion is expected, is a sign of dysfunction. Tissue texture
abnormalities also signify altered function at a segment. Of particular
interest is the palpable presence of hypertonus in intersegmental muscles such
as multifidus. Patterns of pain referral and altered neurological function also
suggest that a vertebral segment is dysfunctional.
The
normalizing function involves restoring motion and enhancing neuromuscular
control at the involved vertebral segment. The restoration of motion is the
goal of manual therapy techniques used in the treatment of spinal dysfunction.
There are many hypothesized causes of vertebral somatic dysfunction and
specific manual therapy techniques have been developed to address each hypothesis.
The focus of this section is to explore the concepts behind the use of muscle
energy techniques in the evaluation and treatment of vertebral somatic
dysfunction and lumbar spine pain.
Normal
Vertebral Segment Motion
The identification of abnormal vertebral segment motion requires an understanding of normal vertebral segment motion. Normal motion at a lumbar vertebral segment with flexion and extension can be described as follows:
Flexion: The superior vertebral body rotates in relation to the inferior vertebral body around a transverse axis so that the anterior intervertebral space narrows while the posterior intervertebral space widens. The superior vertebral body also translates anteriorly on the inferior vertebral body of the segment. The inferior articulating processes of the superior vertebra glide superiorly on the superior articulating processes of the inferior vertebra of the segment. No side bending or rotation should occur if the movement stays within the sagittal plane.
Extension: The superior vertebral body rotates in relation to the inferior vertebral body around a transverse axis so that the anterior intervertebral space widens while the posterior intervertebral space narrows. The superior vertebral body also translates posteriorly on the inferior vertebral body of the segment. The inferior articulating processes of the superior vertebra glide inferiorly on the superior articulating processes of the inferior vertebra of the segment. No side bending or rotation should occur if the movement stays within the sagittal plane.
Symmetrical movement at the vertebral segment should occur if the movement is kept within the sagittal plane. With injury or adaptive changes, motion at a segment may become symmetrically reduced (hypomobility) or increased (hypermobility) or become asymmetrical. These changes in the quantity and/or quality of segmental motion help the clinician identify altered function at a vertebral segment. Of particular interest to muscle energy practitioners are the asymmetrical motion patterns that occur when symmetry is expected.
The identification of abnormal vertebral segment motion requires an understanding of normal vertebral segment motion. Normal motion at a lumbar vertebral segment with flexion and extension can be described as follows:
Flexion: The superior vertebral body rotates in relation to the inferior vertebral body around a transverse axis so that the anterior intervertebral space narrows while the posterior intervertebral space widens. The superior vertebral body also translates anteriorly on the inferior vertebral body of the segment. The inferior articulating processes of the superior vertebra glide superiorly on the superior articulating processes of the inferior vertebra of the segment. No side bending or rotation should occur if the movement stays within the sagittal plane.
Extension: The superior vertebral body rotates in relation to the inferior vertebral body around a transverse axis so that the anterior intervertebral space widens while the posterior intervertebral space narrows. The superior vertebral body also translates posteriorly on the inferior vertebral body of the segment. The inferior articulating processes of the superior vertebra glide inferiorly on the superior articulating processes of the inferior vertebra of the segment. No side bending or rotation should occur if the movement stays within the sagittal plane.
Symmetrical movement at the vertebral segment should occur if the movement is kept within the sagittal plane. With injury or adaptive changes, motion at a segment may become symmetrically reduced (hypomobility) or increased (hypermobility) or become asymmetrical. These changes in the quantity and/or quality of segmental motion help the clinician identify altered function at a vertebral segment. Of particular interest to muscle energy practitioners are the asymmetrical motion patterns that occur when symmetry is expected.
Laws
of Physiologic Spinal Motion
Harrison Fryette proposed three laws of physiologic spine motion that help clinicians interpret asymmetrical motion patterns found during an examination. Fryette’s Laws can be summarized as follows:
Law I. If the anterior-posterior (AP) curve of the spine is in a neutral or mid-range position, side bending and rotation occur to opposite sides.
Law II. If the spinal segment is in a non-neutral (flexed or extended) position, side bending and rotation occur to the same sides. This coupling of movement is due to the influence of the zygapophyseal joints upon segmental motion.
Law III. If a segment is moved into one of the cardinal planes of motion, the available motion in the other two planes is reduced.
Harrison Fryette proposed three laws of physiologic spine motion that help clinicians interpret asymmetrical motion patterns found during an examination. Fryette’s Laws can be summarized as follows:
Law I. If the anterior-posterior (AP) curve of the spine is in a neutral or mid-range position, side bending and rotation occur to opposite sides.
Law II. If the spinal segment is in a non-neutral (flexed or extended) position, side bending and rotation occur to the same sides. This coupling of movement is due to the influence of the zygapophyseal joints upon segmental motion.
Law III. If a segment is moved into one of the cardinal planes of motion, the available motion in the other two planes is reduced.
Vertebral
Somatic Dysfunction
Osteopathic literature identifies two types of vertebral somatic dysfunction that are based on Laws I and II.
Vertebral somatic dysfunction is classified as Type I when a positional asymmetry is identified with the spine in a neutral sagittal plane position. Type I somatic dysfunction is multi-segmental and adaptive in nature. Its positional asymmetry presents in accordance with Law I, therefore, side bending and rotation of the motion segment occur to opposite sides. With positional testing, a neutral (Type I) dysfunction is identified when multiple segments have posterior transverse processes on the same side in all three testing positions. The positional asymmetry of the transverse processes is decreased in the flexed and extended test positions. A scoliotic spinal curve is an example of this type of dysfunction. Groups of vertebra are treated as a functional unit when addressing neutral (Type I) vertebral somatic dysfunction.
Type II vertebral somatic dysfunction reveals a positional asymmetry when the spine is in a non-neutral (flexed or extended) sagittal plane position. Type II dysfunction is usually found at a single spinal segment and is traumatic in origin. Its positional asymmetry presents in accordance with Law II, therefore, side bending and rotation of the motion segment occurs to the same side. With positional testing, a non-neutral (Type II) dysfunction is identified if one transverse process is more posterior in the flexed position (revealing an asymmetry) and then becomes more symmetrical in the extended position. A non-neutral (Type II) dysfunction is also identified if one transverse process is more posterior in the extended position (revealing an asymmetry) and then becomes more symmetrical in the flexed position.
Osteopathic literature identifies two types of vertebral somatic dysfunction that are based on Laws I and II.
Vertebral somatic dysfunction is classified as Type I when a positional asymmetry is identified with the spine in a neutral sagittal plane position. Type I somatic dysfunction is multi-segmental and adaptive in nature. Its positional asymmetry presents in accordance with Law I, therefore, side bending and rotation of the motion segment occur to opposite sides. With positional testing, a neutral (Type I) dysfunction is identified when multiple segments have posterior transverse processes on the same side in all three testing positions. The positional asymmetry of the transverse processes is decreased in the flexed and extended test positions. A scoliotic spinal curve is an example of this type of dysfunction. Groups of vertebra are treated as a functional unit when addressing neutral (Type I) vertebral somatic dysfunction.
Type II vertebral somatic dysfunction reveals a positional asymmetry when the spine is in a non-neutral (flexed or extended) sagittal plane position. Type II dysfunction is usually found at a single spinal segment and is traumatic in origin. Its positional asymmetry presents in accordance with Law II, therefore, side bending and rotation of the motion segment occurs to the same side. With positional testing, a non-neutral (Type II) dysfunction is identified if one transverse process is more posterior in the flexed position (revealing an asymmetry) and then becomes more symmetrical in the extended position. A non-neutral (Type II) dysfunction is also identified if one transverse process is more posterior in the extended position (revealing an asymmetry) and then becomes more symmetrical in the flexed position.
Type II
vertebral somatic dysfunction is commonly found in the athletic setting. It
typically involves a limitation of motion into only one quadrant (i.e. flexion,
right side bending and right rotation). A single zygapophyseal joint is
hypothesized to be the site of limited motion. Muscle hypertonus, joint
subluxation or loose bodies are proposed causes of this single quadrant
limitation of segmental motion. The normalization of muscle tone of
intersegmental muscles (e.g. multifidus) is the aim of muscle energy techniques
used to treat Type II dysfunction. Restoring normal muscle tone to
intersegmental muscles is thought to allow normal motion the vertebral segment.
Treatment is directed at a single vertebral motion segment when addressing
non-neutral (Type II) vertebral somatic dysfunction.
Non-Neutral
(Type II) Vertebral Somatic Dysfunction
The specific dysfunction is labeled by the position the zygapophyseal joint is stuck in and the asymmetrical position the segment assumes when it is moved in the direction of restricted motion. The three-dimensional motion restricted at the vertebral segment is diagonally opposite to the diagnostic label given to the dysfunction. There are four potential positional diagnoses for single quadrant limitations of segmental motion: ERSR, ERSL, FRSR and FRSL. These diagnoses are based upon osteopathic terminology and are commonly used in muscle energy and joint mobilization systems of treatment.
FRSR - Flexed, Rotated and Side bent to the Right
This term describes the asymmetrical movement of the superior vertebra during extension of the segment if the left zygapophyseal joint is unable to close (the inferior articular process of the superior vertebra is unable to glide inferior on the superior process of the inferior vertebra). If the left zygapophyseal joint is stuck in an open or flexed position (it can not extend), the superior vertebra will side bend to the right as the segment is extended. In accordance with Law II, the superior vertebra will also rotate to the right. The right rotation of the superior vertebra will cause its right transverse process to move posterior in relation to the left transverse process and the right transverse process below. The posterior position of the right transverse process of the superior vertebra can be palpated with the patient in an extended spinal posture. When a zygapophyseal joint is unable to close with extension, the posterior transverse process will be on the opposite side as the zygapophyseal joint that is stuck. The positional diagnosis would indicate that the superior vertebra is Flexed, Rotated and Side bent to the Right. This dysfunction at the L4/5 segment would be recorded as L4 FRSR. The restricted motion at the segment is Extension, Rotation and Side bending to the Left. If using a direct treatment technique like muscle energy, the motion restricted will be the three-dimensional direction the dysfunctional segment is moved toward during treatment.
The specific dysfunction is labeled by the position the zygapophyseal joint is stuck in and the asymmetrical position the segment assumes when it is moved in the direction of restricted motion. The three-dimensional motion restricted at the vertebral segment is diagonally opposite to the diagnostic label given to the dysfunction. There are four potential positional diagnoses for single quadrant limitations of segmental motion: ERSR, ERSL, FRSR and FRSL. These diagnoses are based upon osteopathic terminology and are commonly used in muscle energy and joint mobilization systems of treatment.
FRSR - Flexed, Rotated and Side bent to the Right
This term describes the asymmetrical movement of the superior vertebra during extension of the segment if the left zygapophyseal joint is unable to close (the inferior articular process of the superior vertebra is unable to glide inferior on the superior process of the inferior vertebra). If the left zygapophyseal joint is stuck in an open or flexed position (it can not extend), the superior vertebra will side bend to the right as the segment is extended. In accordance with Law II, the superior vertebra will also rotate to the right. The right rotation of the superior vertebra will cause its right transverse process to move posterior in relation to the left transverse process and the right transverse process below. The posterior position of the right transverse process of the superior vertebra can be palpated with the patient in an extended spinal posture. When a zygapophyseal joint is unable to close with extension, the posterior transverse process will be on the opposite side as the zygapophyseal joint that is stuck. The positional diagnosis would indicate that the superior vertebra is Flexed, Rotated and Side bent to the Right. This dysfunction at the L4/5 segment would be recorded as L4 FRSR. The restricted motion at the segment is Extension, Rotation and Side bending to the Left. If using a direct treatment technique like muscle energy, the motion restricted will be the three-dimensional direction the dysfunctional segment is moved toward during treatment.
Non-Neutral
(Type II) Vertebral Somatic Dysfunction
The specific dysfunction is labeled by the position the zygapophyseal joint is stuck in and the asymmetrical position the segment assumes when it is moved in the direction of restricted motion. The three-dimensional motion restricted at the vertebral segment is diagonally opposite to the diagnostic label given to the dysfunction. There are four potential positional diagnoses for single quadrant limitations of segmental motion: ERSR, ERSL, FRSR and FRSL. These diagnoses are based upon osteopathic terminology and are commonly used in muscle energy and joint mobilization systems of treatment.
ERSR - Extended, Rotated and Side bent to the Right
This term describes the asymmetrical movement of the superior vertebra during flexion of the segment if the right zygapophyseal joint is unable to open (the inferior articular process of the superior vertebra is unable to glide superior on the superior process of the inferior vertebra). If the right zygapophyseal joint is stuck in a closed or extended position (it can not flex), the superior vertebra will side bend to the right as the segment is flexed. In accordance with Law II, the superior vertebra will also rotate to the right. The right rotation of the superior vertebra will cause its right transverse process to move posterior in relation to the left transverse process and the right transverse process below. The posterior position of the right transverse process of the superior vertebra can be palpated with the patient in a flexed spinal posture. When a zygapophyseal joint is unable to open with flexion, the posterior transverse process will be on the same side as the zygapophyseal joint that is stuck. The positional diagnosis would indicate that the superior vertebra is Extended, Rotated and Side bent to the Right. This dysfunction at the L5S1 segment would be recorded as L5 ERSR. The restricted motion at the segment is Flexion, Rotation and Side bending to the Left. If using a direct treatment technique like muscle energy, the motion restricted will be the three-dimensional direction the dysfunctional segment is moved toward during treatment.
The specific dysfunction is labeled by the position the zygapophyseal joint is stuck in and the asymmetrical position the segment assumes when it is moved in the direction of restricted motion. The three-dimensional motion restricted at the vertebral segment is diagonally opposite to the diagnostic label given to the dysfunction. There are four potential positional diagnoses for single quadrant limitations of segmental motion: ERSR, ERSL, FRSR and FRSL. These diagnoses are based upon osteopathic terminology and are commonly used in muscle energy and joint mobilization systems of treatment.
ERSR - Extended, Rotated and Side bent to the Right
This term describes the asymmetrical movement of the superior vertebra during flexion of the segment if the right zygapophyseal joint is unable to open (the inferior articular process of the superior vertebra is unable to glide superior on the superior process of the inferior vertebra). If the right zygapophyseal joint is stuck in a closed or extended position (it can not flex), the superior vertebra will side bend to the right as the segment is flexed. In accordance with Law II, the superior vertebra will also rotate to the right. The right rotation of the superior vertebra will cause its right transverse process to move posterior in relation to the left transverse process and the right transverse process below. The posterior position of the right transverse process of the superior vertebra can be palpated with the patient in a flexed spinal posture. When a zygapophyseal joint is unable to open with flexion, the posterior transverse process will be on the same side as the zygapophyseal joint that is stuck. The positional diagnosis would indicate that the superior vertebra is Extended, Rotated and Side bent to the Right. This dysfunction at the L5S1 segment would be recorded as L5 ERSR. The restricted motion at the segment is Flexion, Rotation and Side bending to the Left. If using a direct treatment technique like muscle energy, the motion restricted will be the three-dimensional direction the dysfunctional segment is moved toward during treatment.
Non-Neutral
(Type II) Vertebral Somatic Dysfunction
The specific dysfunction is labeled by the position the zygapophyseal joint is stuck in and the asymmetrical position the segment assumes when it is moved in the direction of restricted motion. The three-dimensional motion restricted at the vertebral segment is diagonally opposite to the diagnostic label given to the dysfunction. There are four potential positional diagnoses for single quadrant limitations of segmental motion: ERSR, ERSL, FRSR and FRSL. These diagnoses are based upon osteopathic terminology and are commonly used in muscle energy and joint mobilization systems of treatment.
ERSL - Extended, Rotated and Side bent to the Left
This term describes the asymmetrical movement of the superior vertebra during flexion of the segment if the left zygapophyseal joint is unable to open (the inferior articular process of the superior vertebra is unable to glide superior on the superior process of the inferior vertebra). If the left zygapophyseal joint is stuck in a closed or extended position (it can not flex), the superior vertebra will side bend to the left as the segment is flexed. In accordance with Law II, the superior vertebra will also rotate to the left. The left rotation of the superior vertebra will cause its left transverse process to move posterior in relation to the right transverse process and the left transverse process below. The posterior position of the left transverse process of the superior vertebra can be palpated with the patient in a flexed spinal posture. When a zygapophyseal joint is unable to open with flexion, the posterior transverse process will be on the same side as the zygapophyseal joint that is stuck. The positional diagnosis would indicate that the superior vertebra is Extended, Rotated and Side bent to the Left. This dysfunction at the L3/4 segment would be recorded as L3 ERSL. The restricted motion at the segment is Flexion, Rotation and Side bending to the Right. If using a direct treatment technique like muscle energy, the motion restricted will be the three-dimensional direction the dysfunctional segment is moved toward during treatment.
The specific dysfunction is labeled by the position the zygapophyseal joint is stuck in and the asymmetrical position the segment assumes when it is moved in the direction of restricted motion. The three-dimensional motion restricted at the vertebral segment is diagonally opposite to the diagnostic label given to the dysfunction. There are four potential positional diagnoses for single quadrant limitations of segmental motion: ERSR, ERSL, FRSR and FRSL. These diagnoses are based upon osteopathic terminology and are commonly used in muscle energy and joint mobilization systems of treatment.
ERSL - Extended, Rotated and Side bent to the Left
This term describes the asymmetrical movement of the superior vertebra during flexion of the segment if the left zygapophyseal joint is unable to open (the inferior articular process of the superior vertebra is unable to glide superior on the superior process of the inferior vertebra). If the left zygapophyseal joint is stuck in a closed or extended position (it can not flex), the superior vertebra will side bend to the left as the segment is flexed. In accordance with Law II, the superior vertebra will also rotate to the left. The left rotation of the superior vertebra will cause its left transverse process to move posterior in relation to the right transverse process and the left transverse process below. The posterior position of the left transverse process of the superior vertebra can be palpated with the patient in a flexed spinal posture. When a zygapophyseal joint is unable to open with flexion, the posterior transverse process will be on the same side as the zygapophyseal joint that is stuck. The positional diagnosis would indicate that the superior vertebra is Extended, Rotated and Side bent to the Left. This dysfunction at the L3/4 segment would be recorded as L3 ERSL. The restricted motion at the segment is Flexion, Rotation and Side bending to the Right. If using a direct treatment technique like muscle energy, the motion restricted will be the three-dimensional direction the dysfunctional segment is moved toward during treatment.
Non-Neutral
(Type II) Vertebral Somatic Dysfunction
The specific dysfunction is labeled by the position the zygapophyseal joint is stuck in and the asymmetrical position the segment assumes when it is moved in the direction of restricted motion. The three-dimensional motion restricted at the vertebral segment is diagonally opposite to the diagnostic label given to the dysfunction. There are four potential positional diagnoses for single quadrant limitations of segmental motion: ERSR, ERSL, FRSR and FRSL. These diagnoses are based upon osteopathic terminology and are commonly used in muscle energy and joint mobilization systems of treatment.
FRSL - Flexed, Rotated and Side bent to the Left
This term describes the asymmetrical movement of the superior vertebra during extension of the segment if the right zygapophyseal joint is unable to close (the inferior articular process of the superior vertebra is unable to glide inferior on the superior process of the inferior vertebra). If the right zygapophyseal joint is stuck in an open or flexed position (it can not extend), the superior vertebra will side bend to the left as the segment is extended. In accordance with Law II, the superior vertebra will also rotate to the left. The left rotation of the superior vertebra will cause its left transverse process to move posterior in relation to the right transverse process and the left transverse process below. The posterior position of the left transverse process of the superior vertebra can be palpated with the patient in an extended spinal posture. When a zygapophyseal joint is unable to close with extension, the posterior transverse process will be on the opposite side as the zygapophyseal joint that is stuck. The positional diagnosis would indicate that the superior vertebra is Flexed, Rotated and Side bent to the Left. This dysfunction at the L5S1 segment would be recorded as L5 FRSL. The restricted motion at the segment is Extension, Rotation and Side bending to the Right. If using a direct treatment technique like muscle energy, the motion restricted will be the three-dimensional direction the dysfunctional segment is moved toward during treatment.
If a zygapophyseal joint is unable to open or close, then segmental motion will be restricted in two diagonally opposite quadrants. For example, evaluation procedures may reveal an ERSR and a FRSL at the same segment if the left zygapophyseal joint is unable to flex or extend due to osseous fusion or capsular fibrosis. A right posterolateral disc protrusion may produce apparent ERSL and FRSL positional diagnosis findings because it limits motion the ability of the superior vertebra to right side bend or right rotate in either a flexed or extended position.
The specific dysfunction is labeled by the position the zygapophyseal joint is stuck in and the asymmetrical position the segment assumes when it is moved in the direction of restricted motion. The three-dimensional motion restricted at the vertebral segment is diagonally opposite to the diagnostic label given to the dysfunction. There are four potential positional diagnoses for single quadrant limitations of segmental motion: ERSR, ERSL, FRSR and FRSL. These diagnoses are based upon osteopathic terminology and are commonly used in muscle energy and joint mobilization systems of treatment.
FRSL - Flexed, Rotated and Side bent to the Left
This term describes the asymmetrical movement of the superior vertebra during extension of the segment if the right zygapophyseal joint is unable to close (the inferior articular process of the superior vertebra is unable to glide inferior on the superior process of the inferior vertebra). If the right zygapophyseal joint is stuck in an open or flexed position (it can not extend), the superior vertebra will side bend to the left as the segment is extended. In accordance with Law II, the superior vertebra will also rotate to the left. The left rotation of the superior vertebra will cause its left transverse process to move posterior in relation to the right transverse process and the left transverse process below. The posterior position of the left transverse process of the superior vertebra can be palpated with the patient in an extended spinal posture. When a zygapophyseal joint is unable to close with extension, the posterior transverse process will be on the opposite side as the zygapophyseal joint that is stuck. The positional diagnosis would indicate that the superior vertebra is Flexed, Rotated and Side bent to the Left. This dysfunction at the L5S1 segment would be recorded as L5 FRSL. The restricted motion at the segment is Extension, Rotation and Side bending to the Right. If using a direct treatment technique like muscle energy, the motion restricted will be the three-dimensional direction the dysfunctional segment is moved toward during treatment.
If a zygapophyseal joint is unable to open or close, then segmental motion will be restricted in two diagonally opposite quadrants. For example, evaluation procedures may reveal an ERSR and a FRSL at the same segment if the left zygapophyseal joint is unable to flex or extend due to osseous fusion or capsular fibrosis. A right posterolateral disc protrusion may produce apparent ERSL and FRSL positional diagnosis findings because it limits motion the ability of the superior vertebra to right side bend or right rotate in either a flexed or extended position.
Examination
of Vertebral Segment Motion
Available motion at a vertebral segment can be assessed in many ways. Two of the most common are passive physiological intervertebral motion (PPIVM) testing and positional testing.
Passive physiological intervertebral motion testing involves motion quantity and quality assessment while the vertebral segment is passively moved through its available range of flexion, extension, side bending and rotation by the clinician. The movement between the two spinous processes of the segment is palpated to gain a sense of the motion at that segment.
Available motion at a vertebral segment can be assessed in many ways. Two of the most common are passive physiological intervertebral motion (PPIVM) testing and positional testing.
Passive physiological intervertebral motion testing involves motion quantity and quality assessment while the vertebral segment is passively moved through its available range of flexion, extension, side bending and rotation by the clinician. The movement between the two spinous processes of the segment is palpated to gain a sense of the motion at that segment.
Left Side bending PPIVM Flexion PPIVM
Extension PPIVM Left Rotation PPIVM
Examination
of Vertebral Segment Motion
Available motion at a vertebral segment can be assessed in many ways. Two of the most common are passive physiological intervertebral motion (PPIVM) testing and positional testing.
Positional testing involves monitoring the relative position of the two vertebra of the motion segment in neutral, flexed and extended spinal postures. This assessment technique uses the transverse processes as an indication of vertebral position. The position of the paired transverse processes of superior vertebra of a motion segment is compared to the position of the paired transverse processes of the inferior vertebra of the motion segment to determine if dysfunction is present. The transverse processes are palpated with the patient lying prone (neutral), prone on elbows (extended) and forward bent in sitting (flexed) positions. Palpation should start at the sacral base and progress upward toward the thoracolumbar junction. Positional testing is commonly used by clinicians that use muscle energy techniques.
Available motion at a vertebral segment can be assessed in many ways. Two of the most common are passive physiological intervertebral motion (PPIVM) testing and positional testing.
Positional testing involves monitoring the relative position of the two vertebra of the motion segment in neutral, flexed and extended spinal postures. This assessment technique uses the transverse processes as an indication of vertebral position. The position of the paired transverse processes of superior vertebra of a motion segment is compared to the position of the paired transverse processes of the inferior vertebra of the motion segment to determine if dysfunction is present. The transverse processes are palpated with the patient lying prone (neutral), prone on elbows (extended) and forward bent in sitting (flexed) positions. Palpation should start at the sacral base and progress upward toward the thoracolumbar junction. Positional testing is commonly used by clinicians that use muscle energy techniques.
Palpation
of transverse processes in prone position, Palpation of transverse processes in
extension position
Palpation of transverse processes in
sitting position, flexion, Palpation of multifidus muscle
Treatment
of ERS and FRS Dysfunction
In general, muscle energy techniques used to treat non-neutral (Type II) dysfunction are designed to normalize muscle tone in the intersegmental muscles of the vertebral segment. This is accomplished by positioning the vertebral segment at the three-dimensional barrier to motion and then performing isometric contractions of the hypertonic muscle that is limiting further motion. The gentle muscle contractions help to reset gamma gain in the muscle spindle of the hypertonic muscle. The resetting of gamma gain allows the muscle to lengthen without abnormal resistance and the vertebral segment to move unimpeded through its normal range of motion. The restoration of normal muscle tone and segmental mobility is thought to lead to resolution of the impaired or altered function at the involved vertebral segment.
Muscle Energy Technique for an ERSL Dysfunction:
The motion restriction with this dysfunction is flexion, right rotation and right side bending. The patient is positioned in right side lying. The clinician stands in front of the patient. The patient rotates their chest toward the table (producing right rotation). The patient’s left arm should be off the edge of the table so that the patient can reach toward the floor and aid the production of right trunk rotation to the rotational barrier at the dysfunctional segment. The clinician must palpate the spinous processes of the dysfunctional segment to determine when the barrier to motion is reached. The clinician supports the patient’s knees on his/her right thigh and palpates the dysfunctional segment. The clinician flexes the patient’s hips until the flexion motion barrier at the dysfunctional segment is encountered. While maintaining the patient’s knees on his/her thigh, the clinician allows the patient’s feet to drop toward the floor (producing right side bending) until the barrier to right side bending at the dysfunctional segment is encountered. Once the flexion, rotation and side bending barriers are engaged, the clinician resists the patient’s effort to lift their feet toward the ceiling. This will produce a contraction of the muscles responsible for left side bending of the spine (the muscles thought to be maintaining the dysfunction). The contraction should be held for 3 to 6 seconds. Upon relaxation, the new flexion, right rotation and right side bending barriers to segmental motion should be engaged. The muscle contraction should be repeated at the new three-dimensional barrier. This muscle contraction and repositioning sequence should be repeated 3 to 5 times. The dysfunctional segment should be re-evaluated after the 3 to 5 repetitions.
In general, muscle energy techniques used to treat non-neutral (Type II) dysfunction are designed to normalize muscle tone in the intersegmental muscles of the vertebral segment. This is accomplished by positioning the vertebral segment at the three-dimensional barrier to motion and then performing isometric contractions of the hypertonic muscle that is limiting further motion. The gentle muscle contractions help to reset gamma gain in the muscle spindle of the hypertonic muscle. The resetting of gamma gain allows the muscle to lengthen without abnormal resistance and the vertebral segment to move unimpeded through its normal range of motion. The restoration of normal muscle tone and segmental mobility is thought to lead to resolution of the impaired or altered function at the involved vertebral segment.
Muscle Energy Technique for an ERSL Dysfunction:
The motion restriction with this dysfunction is flexion, right rotation and right side bending. The patient is positioned in right side lying. The clinician stands in front of the patient. The patient rotates their chest toward the table (producing right rotation). The patient’s left arm should be off the edge of the table so that the patient can reach toward the floor and aid the production of right trunk rotation to the rotational barrier at the dysfunctional segment. The clinician must palpate the spinous processes of the dysfunctional segment to determine when the barrier to motion is reached. The clinician supports the patient’s knees on his/her right thigh and palpates the dysfunctional segment. The clinician flexes the patient’s hips until the flexion motion barrier at the dysfunctional segment is encountered. While maintaining the patient’s knees on his/her thigh, the clinician allows the patient’s feet to drop toward the floor (producing right side bending) until the barrier to right side bending at the dysfunctional segment is encountered. Once the flexion, rotation and side bending barriers are engaged, the clinician resists the patient’s effort to lift their feet toward the ceiling. This will produce a contraction of the muscles responsible for left side bending of the spine (the muscles thought to be maintaining the dysfunction). The contraction should be held for 3 to 6 seconds. Upon relaxation, the new flexion, right rotation and right side bending barriers to segmental motion should be engaged. The muscle contraction should be repeated at the new three-dimensional barrier. This muscle contraction and repositioning sequence should be repeated 3 to 5 times. The dysfunctional segment should be re-evaluated after the 3 to 5 repetitions.
Right
sidelying position(ERS treatment) Right sidelying with right trunk rotation
Right
sidelying with right trunk rotation and trunk flexion
Right
sidelying with right trunk rotation, trunk flexion, and right trunk sidebending
(feet to floor)
Right sidelying with right trunk
rotation, trunk flexion, and right trunk sidebending (feet to floor)
Treatment of ERS and FRS Dysfunction
In general, muscle energy techniques used to treat non-neutral (Type II) dysfunction are designed to normalize muscle tone in the intersegmental muscles of the vertebral segment. This is accomplished by positioning the vertebral segment at the three-dimensional barrier to motion and then performing isometric contractions of the hypertonic muscle that is limiting further motion. The gentle muscle contractions help to reset gamma gain in the muscle spindle of the hypertonic muscle. The resetting of gamma gain allows the muscle to lengthen without abnormal resistance and the vertebral segment to move unimpeded through its normal range of motion. The restoration of normal muscle tone and segmental mobility is thought to lead to resolution of the impaired or altered function at the involved vertebral segment.
Muscle Energy Technique for an FRSL Dysfunction:
The motion restriction with this dysfunction is extension, right rotation and right side bending. The patient is positioned in left side lying. The clinician stands in front of the patient. The extension barrier can be engaged by pulling the trunk from posterior to anterior at the level of the dysfunctional segment. This position can be fine-tuned by pushing the left shoulder (and right shoulder with it) in a posterior direction while monitoring the spinous processes of the dysfunctional segment with the other hand. The extension barrier can also be engaged by extending the lower extremities. The right rotation barrier is encountered by pushing the right shoulder posteriorly. This produces right rotation of the trunk. The patient can grab the edge of the table to maintain this position. Next, the clinician finds the barrier to right side bending by lifting the patient’s right leg toward the ceiling (approximately 4 to 6 inches) with his left hand. The spinous processes of the dysfunctional segment are palpated with the clinician’s right hand to assure specificity of treatment. Once the extension, right rotation and right side bending barriers are engaged, the patient is asked to pull down toward the floor with their right (top) leg. This task will produce a contraction of the muscles responsible for left side bending of the segment (the muscles thought to be maintaining the dysfunction). The clinician resists this muscle contraction for 3 to 6 seconds. Upon relaxation, the patient is repositioned at the new extension, right rotation and side bending barriers to segmental motion. The contraction/repositioning sequence should be repeated 3 to 5 times. The dysfunctional segment should be reassessed at the end of the 3 to 5 repetitions.
In general, muscle energy techniques used to treat non-neutral (Type II) dysfunction are designed to normalize muscle tone in the intersegmental muscles of the vertebral segment. This is accomplished by positioning the vertebral segment at the three-dimensional barrier to motion and then performing isometric contractions of the hypertonic muscle that is limiting further motion. The gentle muscle contractions help to reset gamma gain in the muscle spindle of the hypertonic muscle. The resetting of gamma gain allows the muscle to lengthen without abnormal resistance and the vertebral segment to move unimpeded through its normal range of motion. The restoration of normal muscle tone and segmental mobility is thought to lead to resolution of the impaired or altered function at the involved vertebral segment.
Muscle Energy Technique for an FRSL Dysfunction:
The motion restriction with this dysfunction is extension, right rotation and right side bending. The patient is positioned in left side lying. The clinician stands in front of the patient. The extension barrier can be engaged by pulling the trunk from posterior to anterior at the level of the dysfunctional segment. This position can be fine-tuned by pushing the left shoulder (and right shoulder with it) in a posterior direction while monitoring the spinous processes of the dysfunctional segment with the other hand. The extension barrier can also be engaged by extending the lower extremities. The right rotation barrier is encountered by pushing the right shoulder posteriorly. This produces right rotation of the trunk. The patient can grab the edge of the table to maintain this position. Next, the clinician finds the barrier to right side bending by lifting the patient’s right leg toward the ceiling (approximately 4 to 6 inches) with his left hand. The spinous processes of the dysfunctional segment are palpated with the clinician’s right hand to assure specificity of treatment. Once the extension, right rotation and right side bending barriers are engaged, the patient is asked to pull down toward the floor with their right (top) leg. This task will produce a contraction of the muscles responsible for left side bending of the segment (the muscles thought to be maintaining the dysfunction). The clinician resists this muscle contraction for 3 to 6 seconds. Upon relaxation, the patient is repositioned at the new extension, right rotation and side bending barriers to segmental motion. The contraction/repositioning sequence should be repeated 3 to 5 times. The dysfunctional segment should be reassessed at the end of the 3 to 5 repetitions.
Left
sidelying position (FRS treatment)
Left
sidelying, push legs into extension to refine the extension position, Left
sidelying, push right shoulder back to right rotate trunk
Stabilize
right rotation by grabbing the table, Lift right leg to produce right side bending
Push
left shoulder back in left sidelying position to refine extension position
(FRS)
References and Further Reading
Fryette HH. Principles of Osteopathic Technic. Academy of Applied Osteopathy, Carmel, CA, 1966.
Greenman PE. Principles of Manual Medicine (2nd Edition). Williams & Wilkins: Baltimore, 1996.
Mitchell FL Jr. Elements of Muscle Energy. In Basmajian JV, Nyberg R (Eds.) Rational Manual Therapies. Williams & Wilkins: Baltimore, 1993.
Fryette HH. Principles of Osteopathic Technic. Academy of Applied Osteopathy, Carmel, CA, 1966.
Greenman PE. Principles of Manual Medicine (2nd Edition). Williams & Wilkins: Baltimore, 1996.
Mitchell FL Jr. Elements of Muscle Energy. In Basmajian JV, Nyberg R (Eds.) Rational Manual Therapies. Williams & Wilkins: Baltimore, 1993.
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