Generally, back pain caused mainly by any region within the lumbar spine getting nervous system intervention. Thus, back pain arises from muscles, lumbar spine’s disc, fascia, or any ligaments. Keep reading to find out more about low back pain.
Passive movements define mobilisation and are also known as accessory or physiological . It aims at providing short term or long term pain relief. Besides, it helps to restore the functional movements of joint.
Joint mobilisation restores the joint’s function and helps to manage musculoskeletal dysfunction. Besides, it improves the restricted movements of the spine. Muscles, connective tissues and the joints are mainly prone to such restrictions, causing pain. Mobilisation removes this restriction giving relief from pain. Even a deeper and forceful mobilisation can help in decreasing the stiffness in joints. This technique is also known as manual therapy, and physiotherapists perform it.
Effects and Mechanism
Research indicated that manual therapy results in significant neurophysiological and mechanical effects. The exact mechanism of mobilisation and needs further research.
However, the effects produced by the manual therapy, such as effect on the autonomic nervous system, motion range increase, and pain relief, suggests different theories.
Mobilisations use hypoalgesia for pain relief. Hypoalgesia is the process in which the sensitivity of the nervous system to painful stimuli is decreased. Likewise, neurophysiological effects proceed through different mechanisms:
According to pain grating theory, mechano-receptive peripheral afferent nerve stimulation in muscles generates sensory input, interfering with the spinal cord’s nociceptive impulses.
The larger sensory nerves prevent the pain transmission through a smaller nerve to the brain. As a result, the patient will feel relief from the pain. Thus, mobilisation causing mechanoreceptors stimulation uses the mechanism of pain grating for short-term pain relief.
However, this theory explains only the short-term effects of the mobilisation and ignores the mechanisms long-term pain-relieving impact. Therefore, the researcher believes that any high brain mechanism can be the route for long-term consequences of mobilisation.
Research indicates that manual therapy activates the pathways that inhibit pain in the midbrain. This activating effect moved down to the spinal cord and named as descending pathway.
The descending mechanism’s activation pathway suppresses the pain. As a result, the patient feels relieved from the pain.
Moreover, research indicates that mobilisation also suppresses the central pain process regions of the brain.
Another hypothesis is that mobilisation can adapt to the nervous system, causing neural input decrease to the painful site. Besides, mobilisations also increase the pain threshold levels. Moreover, studies suggest that it may be due to the electrochemical changes in threshold potential regulation.
Increasing Motion Range
Mobilisations aim at increasing the motion range of the joint by fibrous tissue stretching. The tissue can “creep” as a result of this stretching. Creep occurs as tissue change shape with the application of constant load.
However, this change is not permanent. The tissues return to their original shape after the removal of load. But, the fantastic thing about this mechanical effect of mobilisation is that it increases the motion range at the joint.
Influence on Autonomic Nervous System
Mobilisation also affects the respiratory rate, blood pressure, and heart rate. Changes in blood component levels, another well-documented consequence of mobilisation, may be related to these sympathetic responses.
Teodorczyk-Injeyan et al. (2006) reported that mobilisation affects the blood component level, reducing inflammatory proteins. Thus, the research indicated that mobilisation could act as an anti-inflammatory mechanism. However, the exact pathway of this mechanism is still unknown.
Bialosky et al. (2009) proposed a connection between the neurophysiological and mechanical effects of the mobilisation. According to him, a chain of neurological responses started after the application of mechanical force. As a result, this manual therapy shows its outcomes.
To provide the evidence for the proposed mechanisms and effects, further research is needed on mobilisation. However, it’s essential to consider the relation of psychological factors and placebo effects on the mobilisation outcomes.
Mobilisation Effects on Pain and Stiffness
Mobilisations induce pressure on the vertebra, increasing joint motion range and producing analgesic effects.
Mobilisations and manual therapy can treat five different symptom groups:
- Momentary jabs of pain
- Pain due to stiffness
- Disorders that are specifically linked to a particular diagnosis
For patients having limited joint function due to stiffness:
- Firstly, use physiological movement to assess the patient’s movement
- Select the movement with limited ROM. Accessory movements can also be used.
- Apply pressure with pisiform or thumb against the vertebrae in the direction of stiff movement.
To move the stiff joint efficiently, Staccato techniques are used before the bordering joints start moving. The staccato needs to be quicker if there’re no symptoms from the joint. On the other hand, movements should be more fluid for moderate symptoms.
Moreover, studies indicate that different lumbar spine’s segment responds differently. For instance, PAs on L3, 4 and 5 cause them to extend and move on one vertebra. On the contrary, the lower L3, 4 and 5 move into flexion relative to L1 and L2.
So, physiotherapists need to know the PA mobilisation effect on neighbouring vertebra segments.
For patients who have limited movement due to severe pain.
- The suffering joint should be placed in a symptom-free position.
- From the physiological and accessory movements, the one with which the patient feels comfortable should be used.
- For painful joint, oscillations in mobilisations should go smooth and even.
- Types of Mobilisations
Mobilisations can relieve the localised pain for about 24 hours. Moreover, it can also induce long-term relief from the pain compared to no treatment. For better pain treatment, a random selection of vertebra should be avoided. Instead, a vertebra with a symptomatic level should be chosen.
With very little friction and no stiffness, pressure is exerted via the thumb or pisiform to achieve high movement amplitudes.
The movement amplitude should be large enough without causing any discomfort. Although mobilisation is hypoalgesic irrespective of movement amplitude, the amplitude of movement increase gradually with the improvement in symptoms.
Physiological movements should not cause any pain.
All the movements should be slow, smooth and painless. However, the technique can be used with a controlled degree of pain to improve the patient’s ROM and symptoms.
Mobilisation techniques may be used in a variety of positions using large and small movement amplitudes. There’re four grades of mobilisation.
Grade of Movement
I A large-amplitude of movement that can occupy any spam-free and stiffness free-range.
II A small-amplitude movement from the starting point of the range
III A small-amplitude movement causing muscle spasm and stiffness
IV Lastly, a large-amplitude movement that doesn’t lead to muscle spam and stiffness
Precautions to Vertebral Mobilisations
- The patient having neurological symptoms and arm pain from two different nerve routes. For instance; Disturbance of bowel function and bladder, or signs of Spinal cord perineal anaesthesia
- Patients with osteoporosis and rheumatoid arthritis should not go for forceful mobilisations. Any pathology, such as fracture, corticosteroid medication or tumours that results in bone weakening
- Vertigo patients need constant monitoring
- Avoid putting strain on a hybermobile joint.
Avoid using manual therapy during
- Severe haemophilia such as bleeding into joints and aortic aneurysm
- Musculoskeletal deformities such as spondylolisthesis and Spondylolysis
Mobilisations of the Lumbar Spine
Passive Physiological Intervertebral Movements (PPIVMs)
Passive Physiological Intervertebral Movements (PPIVMs) are not a treatment therapy but have importance in assessment capacity. PPIVMs determine various spinal movement properties to guide the manual therapy techniques.
PPIVMs apply the passive physiological motion to test the movement range at the spinal level. Besides, it uses the articular facets and palpating between the adjacent spinous process for the same purpose.
Therapists can observe the motion range, pain provocation or muscle spam with the passive movement of the spine. They can identify hypermobility and motion restriction in any active movement.
Moreover, therapists can also determine the end-feel of movement by applying the pressure to the end-range of the spine. In this way, therapists can identify the location, severity, nature of the symptoms with the help of PPIVMs.