All across the country, there are a significant number of physical therapists and chiropractors still mobilizing and manipulating their patients lumbar spine. The prevailing thought used to be, and to many still is, that these segments (as if they can tell which segment they are actually pushing on) were stiff and needed to move more. Even better for the practitioner if the area they were pushing on matched up with the patient's area of pain!

What we as practitioners need to be able to reflect upon is "why would the segment that moves too little be painful? When an orthopedist sees a patient with wrist, shoulder, or neck pain what used to be their first response? They would stabilize the joint through the use of a brace, sling, or collar. For patients with low back pain, a common tool that helps ease their pain is a lumbar corset.

As practitioners we realize the effect prolonged use of these external stabilization devices has on the intrinsic dynamic stabilizers (muscles) of these joints, they become inhibited (not necessarily weak, more on this in another post). So to circle back, what is happening when we are pushing on a painful and stiff joint? Are we feeling the body's inherent response which is to stabilize a joint that may otherwise be moving too much? The common sense answer would be YES! Why would we try to remove the bodies natural protection mechanism for a hypermobile joint, is this going to create more dysfunction? A false sense of security by decreasing pain without addressing the cause? What are the possible central and peripheral ramifications then if a patient is given a sense of health only to have the injury become recurrent?

"So Chris, are you saying that we shouldn't mobilize/manipulate our patient's lumbar spines?" No, this is not necessarily the case, but we need to understand that our goal needs to be modified. Rather than focusing on "restoring mobility" to an already hypermobile segment we need to approach our intervention from a pain science standpoint and recognize that we need to be concentrating on decreasing the threat level of movement through this particular segment through repeated non-noxious stimulus or a single high velocity maneuver which research shows is actually just decreasing local muscle tone and changing pain fiber excitability.

SOURCES:

http://ptjournal.apta.org/content/75/9/786.short

http://www.ncbi.nlm.nih.gov/pubmed/14589467

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