Friday, July 31, 2009

Assessment of the spine asymmetry

Modern manual therapy techniques focus on asymmetry in anatomy & mobility and lateralization. Wylick HV et al recommend a 3 Minuit test battery by 8 tests. How ever following are 10 tests to know the asymmetry in spine:

1. Dominant eye
2. Phoria of eye
3. Scooping
4. Step forward
5. Finger crossing
6. Step on platform
7. Axis rotation
8. Tailor’s position
9. Step backward
10. Arm crossing

Sunday, July 26, 2009

Taxonomy to describe treatments for musculoskeletal pain

According to Rubik & colleagues (1994) massage therapy, the manual manipulation of soft body tissues to enhance health and well-being, is one of the oldest forms of medicine known to mankind and has been practiced worldwide since ancient times. Today, more than 80 different forms of massage have been identified, many developed in the last 30 years.

Lack of consistent terminology for describing the treatments given by therapists are felt world wide. Sherman & colleagues developed taxonomy to describe therapist guided module delivery for patients with musculoskeletal pain. Due to this work a new classification system evolved. Using this, practitioners using different styles of extramural medicine (manual medicine technique) can describe the techniques they employ using consistent terminology.

About the study:

A review of the literature for treatment musculoskeletal pain was done for creating the taxonomy & neck pain was the matter subjected to further studies. The results ware as follows:

1. The taxonomy was conceptualized as a 3 classification system

a. principal goals of treatment
b. styles
c. techniques

2. 4 described the principal goal of treatment

a. relaxation massage
b. clinical massage
c. movement re-education
d. energy work

3. Each principal goal of treatment could be met using a number of different styles, with each style consisting of a number of specific techniques.

A total of 36 distinct techniques were identified. Still many of these techniques could be included in multiple styles.

Following is a description principal goal directed treatments:

1. Relaxation massage is massage that is specifically given to relax the body and promote wellness. Relaxation massage has the intention of moving body fluids (such as lymph and blood), nourishing cells, removing wastes from cells, relaxing muscles and diminishing any pain. In the US, the most widely taught and practiced style of relaxation massage is Swedish massage, which employs five basic strokes: effleurage (gliding), petrissage (kneading and lifting), friction (moving the tissue layers underneath the skin), vibration, and percussion. Other common styles include spa massage and sports massage. Relaxation massage may include styles of massage that are more commonly used to address non-relaxation goals if such styles are applied with the intent to relax the body. For example, lymphatic drainage, commonly used as part of clinical massage (e.g., to reduce inflammation), is believed to be effective in stimulating the parasympathetic nervous system to promote relaxation.

2. Clinical massage involves more focused manipulation of the muscle and/or surrounding fascia and may address other systems in the body such as lymphatic, circulatory and nervous systems. Its intent is to relieve pain and restricted movement. Popular styles of clinical massage are myofascial trigger point therapy, myofascial release, neuromuscular therapy and Structural Integration or Rolfing®. They differ from relaxation massage because they include focused therapeutic goals (e.g., releasing muscle spasms, strengthening or stretching specific muscles and remodeling fascia). Clinical massage may include styles of massage often used for other principal goals. For example, Muscle Energy Technique, often used for enhancing ease of movement (movement re-education), can also be used as a clinical technique, for example, to reduce muscle spasms in a patient with whiplash.

3. Movement re-education emphasizes using movement to enhance posture, body awareness and movement. Movement re-education is generally intended to induce a sense of freedom, ease and lightness in the body. Some styles of movement re-education focus on active exercises to teach healthier ways of moving (e.g, Alexander technique, Trager®, Feldenkrais®). These styles may be used by non – massage therapists. Other styles focus on tablework in which the practitioner induces, assists or resists movement for a patient (e.g., Proprioceptive Neuromuscular Facilitation, Muscle Energy Technique, strain counterstrain). Some styles of massage commonly used for a different treatment goal, can be used to increase function and movement (e.g., sports massage).

4. Energy work (also called subtle energy techniques or body-mind therapies) are believed to "assist the flow of energy in the body" by employing very light touch or by holding the hands just above the skin. These include Reiki, Polarity and Therapeutic Touch as well as massage traditions deriving from Eastern cultures, such as acupressure, Amma, Shiatsu and Tuina. The intention of energy work is to move stagnant or blocked "energy" so it can circulate freely throughout the body.

Our questions:

1. What is the definition of massage?
2. What is Classification of massage?
3. How movement reeducation is a massage?
4. Many authorities do not even consider myofascial release as a massage (Dr. AGK Sinha: Author: therapeutic massage).

Our Comment:

Bottom line: The taxonomic classification must be included in syllabus text of concerned courses. It goads the students, teachers & professionals have protocols to follow which further brings clarity in module delivery & determining success of a treatment plan.


Sherman KJ et al; BMC Complement Altern Med. 2006 Jun 23;6:24.

Monday, July 20, 2009

Hypoalgesic Mechanism in Mulligan techniques: A comparison of peripheral & spinal manual therapy produced mechanisms

Mulligan's mobilization with movement treatment technique for the elbow (MWM), a peripheral joint mobilization technique, produces a substantial and immediate pain relief in chronic lateral epicondylalgia. Abbott JH & colleagues reported MWM is a promising intervention modality for the treatment of patients with Lateral Epicondylalgia. They found immediate impact on grip strength in making it pain-free (48% increase in pain-free grip strength). Both pain-free grip strength and maximum grip strength of the affected limb increased significantly following the intervention. Pain-free grip strength increased by a greater magnitude than maximum grip strength.

Non-opioid pain modulation of spinal manual therapy: Naloxone antagonism and tolerance studies, which employ widely accepted tests for the identification of endogenous opioid-mediated pain control mechanisms, have shown that spinal manual therapy-induced hypoalgesia does not involve an opioid mechanism.

However immediate hypoalgesia has been reported by Mulligan’s MWMs have not been studied. Where as amplitude of hypoalgesic effect associated with MWMs is far greater than that previously reported with spinal manual therapy treatments. This prompted a debate that peripheral manual therapy treatments may differ in mechanism of action to spinal manual therapy techniques.

Paungmali & colleagues studied the effect of naloxone administration on the hypoalgesic effect of MWM. This study was a RCT administering naloxone, saline, or no-substance control injection on the MWM-induced hypoalgesia in 18 participants with lateral epicondylalgia. The outcome measures ware:

1. Pain-free grip strength
2. Pressure pain threshold
3. Thermal pain threshold and
4. Upper limb neural tissue provocation test 2b.

This study found that initial hypoalgesic effect of the MWM was not antagonized by naloxone. Which indicates that peripheral mobilization treatment technique appears to have a similar effect profile (nonopioid-mediated hypoalgesia) to previously studied spinal manual therapy techniques.


1. Abbott et al; Man Ther. 2001 Aug;6(3):163-9.

2. Pangumali et al; J Manipulative Physiol Ther. 2004 Mar-Apr;27(3):180-5.



Fibromyalgia syndrome includes symptoms of widespread, chronic musculoskeletal aching and stiffness and soft tissue tender points. It is frequently accompanied by fatigue and sleep disturbance (1). The impact of the disease is considerable both for those directly affected (restriction in activities of daily living and in ability to take part in family, professional, and social life) and for society as a whole (direct and indirect costs) (4). Fibromyalgia requires a comprehensive treatment care (2).


Fibromyalgia is a fairly common syndrome characterized by chronic, widespread musculoskeletal pain, multiple "tender points", fatigue, sleep disturbance, stiffness and other symptoms such as headache, dizziness, trouble with concentration, irritable bowel syndrome, urinary urgency, depression (2). The disease usually has a chronic course (3).


Fibromyalgia is a common chronic pain syndrome affecting particularly middle aged women as it occurs at a mean age of 49 years (1, 4). However, according to Polańska (2) fibromyalgia may occur at any age, even in childhood. The prevalence is about 3.5% for women and 0.5% for men (3).

Signs & symptoms:

The cause of fibromyalgia is unknown. It is difficult to diagnose because many of the symptoms are similar to symptoms of other disorders (2). However, the symptomatology is characterized by diffuse widespread myofascial pain and tenderness on palpation at multiple "tender points" (3). The characteristic symptoms of fibromyalgia are chronic widespread musculoskeletal pain in various parts of the body and abnormal tenderness at 18 specified tender points (4).

Additional symptoms are various vegetative and functional disorders, nonrestorative sleep, depression and anxiety. It also includes stiffness, sleep disorders, fatigue, and problems with concentration (3, 4).


Etiology and pathogenesis of fibromyalgia still remain unclear. Current pathogenetic theories conceptualize a combination of biological and psychic, social and mental factors (4). However researchers points to an abnormality of the central pain-processing mechanisms is highly relevant for the pathogenesis (3).
The pain and fatigue reported by individuals with fibromyalgia results in a relative sedentary lifestyle, hence also a decrease in the fitness level of skeletal muscles (6).

Lab. Investigations:

There are no laboratory tests that can confirm a diagnosis of fibromyalgia. Laboratory examinations and imaging only provide nonconclusive results (2, 4).


Average time from onset to diagnosis is 5-8 years (2). Diagnosis is based on the characteristic clinical presentation, the presence of multiple tender points and the exclusion of certain disorders with similar symptoms (4). But differential diagnosis must include myofascial pain syndrome and chronic fatigue syndrome (1).

Treatments :

Fibromyalgia is a multifactorial problem and no universal treatment guidelines apply to all cases (1). As we know upto yet, fibromyalgia is a chronic widespread unexplained musculoskeletal pain syndrome with decreased pain threshold (6). In addition to early diagnosis and intensive patient education, pharmacotherapy, exercise therapy, behavior therapy, and multidisciplinary treatment are particularly important for the management of fibromyalgia (3).

Because the etiology of fibromyalgia is unknown and the pathogenesis is unidentified, treatment is largely symptomatic and not standardized (6). Pharmacologic therapy may include common pain medications & tricyclic antidepressants (1).

However, patient education, reassurance and an exercise program can each play an important role in relieving the symptoms associated with this common musculoskeletal syndrome (1). However, combination of medication and physical therapies only accomplish some temporary symptomatic relief (30-50%) (4).

Impact of exercises on fibromyalgia pain:

Kurtze (6) reviewed the effect of exercise in fibromyalgia from the Cochrane Controlled Trials Register. He selected 17 studies of exercise interventions on cardiorespiratory endurance, muscle strength and/or flexibility. The group exercises varied from 1-3 times per week, sessions from 25 minutes to 90 minutes; the duration of the programmes from 6 weeks to 6 month.

However, low-intensity aerobic exercise regimens were found to be one of the few effective treatments. Most of the programmes were low-intensity dynamic endurance training with a working rate at 50-70 % of maximal heart rate in relation to age.

Analysis of these studies shows inconsistent of these above said interventions (i.e. cardiorespiratory endurance, muscle strength and/or flexibility). These studies also reveal subjective pain levels fail to show significant improvement, although improvements are seen on other parameters such as improvement in the number of tender points, in total myalgic scores and reduced tender point tenderness, improved aerobic capacity, physical function, subjective well-being and self-efficacy.

Hence Fürst’s (4) conclusion on rehabilitation of fibromyalgia sounds apt. According to him psychosomatic rehabilitation should not focus on reduction of pain, but rather on physical reconditioning and development of an active coping style. Hence in these context psychological interventions, education and psychotherapy are essential (4).

Multidimensional rehabilitation (5):

Multidimensional rehabilitation: According to Wigers & colleagues multidimensional rehabilitation is an effective intervention for patients with widespread chronic pain. They studied 200 patients with chronic myofascial pain and/or fibromyalgia who participated in a 4-week multidimensional rehabilitation programme. Work capacity, a tender point count and whether patients met the diagnostic criteria for fibromyalgia were assessed at baseline and at discharge.

The programme included:

1. Education and pain management in a cognitive setting,
2. Various forms of aerobic exercises,
3. Myofascial pain treatment,
4. Relaxation and
5. Medication as needed.

Wigers & colleagues found:

1. Significant improvements were seen in all variables throughout the follow-up period.
2. 30% of the fibromyalgia patients no longer met the diagnostic criteria at discharge.
3. There was a significant increase in quality of life over time.
4. After one year, more patients had returned to work than not. And fewer people took sick leaves.
5. The majority did exercise training on a regular basis.
Measurements in this study: The patients filled in questionnaires on arrival, at follow-up after six and 12-months and at discharge.

They completed:

1. VAS- visual analogue scales ( for pain, fatigue, sleep problems, depression)
2. Nottingham Health Profile
3. Fibromyalgia Impact Questionnaire

The following ware also assessed:

1. Global subjective improvement
2. Physical activity level,
3. Changes in quality of life and
4. Occupational workload.


1. Reiffenberger DH et al; Am Fam Physician. 1996 Apr;53(5):1698-712.
2. Polańska B; Pol Merkur Lekarski. 2004 Jan;16(91):93-6.
3. Jäckel WH et al; Z Rheumatol. 2007 Nov;66(7):579-90.
4. Fürst G; Wien Med Wochenschr. 2007 Jan;157(1-2):27-33.
5. Wigers SH et al; Tidsskr Nor Laegeforen. 2007 Mar 1;127(5):604-8.
6. Kurtze N; Tidsskr Nor Laegeforen. 2004 Oct 7;124(19):2475-8.

Saturday, July 18, 2009

Autologous blood injections for refractory lateral epicondylitis.

(Part of one of my paper in a upcoming journal……….)

Lateral epicondylitis is degenerative than an inflammatory process. Old treatment methods based on anti-inflammatory module delivery are facing theoretical nihilism. Currently few researchers are trying to inject autologous blood in to the painful area of the lateral elbow. The thought behind injection of autologous blood in such case is; it might provide the necessary cellular and humoral mediators to induce a healing cascade.

Example of a study:
Edwards SG et al injected 2ml autologous blood under the extensor carpi radialis brevis to treat refractory lateral epicondylitis. All patients had failed previous nonsurgical treatments including all or combinations of physical therapy, splinting, nonsteroidal anti-inflammatory medication, and prior steroid injections. The average follow-up period Edwards SG et al’s study was 9.5 months (range, 6-24 months).

They found:
After autologous blood injection therapy 22 patients (79%) in whom nonsurgical modalities had failed were relieved completely of pain even during strenuous activity. However we found quality of this study was not up to mark as it lacked good sample size, randomization and evaluation through standardized outcome measures etc.

More evidence required from keen researchers.

Thursday, July 16, 2009

My experience of thoracic mobilization & MFR on upper posterior thoracic level on vasospasm of distal hind limb

(This is a form of MFR to upper anterior thoracic )

Many hemiplegics presents with shoulder hand syndrome. Shoulder hand syndrome is also known as CRPS (complex regional pain syndrome) or RSD (reflex sympathetic dystrophy).

In past and also recently I have used SPAM to mid thoracic vertebrae & MFR to upper posterior thoracic level (precisely in physiotherapeutic terms bilateral rhomboidus stretch) with moderate results on pain & disability plus overall reduction menifestation of RSD in my patients.

Peers usually associate these effects of mobilization & MFR with autonomic balancing act in the zone. Various grades of touch has been shown to affect central neuronal out puts to endocrine perturbations. Myofacial release is unique in this aspect however not many research papers are there. Relief of vasospasm by MFR is claimed by researcher Walton in 2008. Following is a micro review of that paper that found MFR is a effective modality in treatment of primary Raynaud's phenomenon:

Walton investigated whether MFR techniques performed on upper body connective tissue could ease the frequency, duration or pain intensity associated with primary Raynaud's phenomenon.
The myofascial work targeted the upper back, neck and arms according to hypothetical fascial meridian lines & he administered 5 treatments over a 3-week treatment period on a 35-year-old female experiencing primary Raynaud's phenomenon for the past 12 years.

After the first treatment, the duration of the subject's vasospastic episodes was reduced by almost half and continued to decrease throughout the 3 weeks of treatments. However, the frequency or number of affected digits showed insignificant changes.

These results suggest that by releasing restricted fascia, myofascial techniques may influence the duration and severity of the vasospastic episodes experienced in primary Raynaud's phenomenon.


J Bodyw Mov Ther. 2008 Jul;12(3):274-80. Epub 2008 Mar 5.

Wednesday, July 15, 2009

A specific manual therapy technique called “Muscle Repositioning or neuro-myofascial release” mimic the action of pandiculation.

Pandiculation (whole body stretch)

We like to stretch our whole body after getting off the bed which usually comes with a yawning. This stretch is different form the regular stretching exercise we do. Noteworthy is the difference between the pandiculation-type stretch, which arises spontaneously, is pleasurable and increases joint stability, with the regular stretching, which is produced by a volitional action, may produce displeasure and joint instability (because of this, stretching has been contraindicated before physical activity).

Pandicular stretching activity is remarkably reduced after spine & proximal appendicular pathologies (Luiz Fernando Bertolucci).

Following is more on the description of Pandiculation form following site:

The symmetrical, coordinated stretching and stiffening actions of the body as one unit is true pandiculation. This action typically occurs in man and animals alike, as an exertion which sweeps wavelike through the subject's' main articular parts, extending them distally. In each pandiculation there is a chain of actions, notably of the head, neck and limbs which are coordinated in stretching; yawning is sometimes involved among these articular extensions. Pandiculation is, in fact, a very characteristic phenomenon with overall stretching as its core. Modern neuroethology has shed light on the physiological background.

Possible functions of pandiculation: Because pandiculation is seen animal kingdom & also in developing human fetus it is believed to have a role in the development and maintenance of the musculoskeletal system (Fraser & Walusinski). According to Luiz Fernando Bertolucci (a physiatrist, a rolfing specialist & a researcher) pandiculating helps maintain the integrative function of the fascial system by:

(a) Mechanical signaling the connective tissue metabolism (mechanotransduction) to reinforce the collagen links that unites the segments to one another, as when one pandiculates,
(b) Redistribution of free water (water that can flow) in the extracellular matrix.

This latter effect stabilizes the joints and thus also increases the degree of integration, among other hypothetical mechanisms.

Muscle repositioning or Neuro-myofascial release: (Conceptualized by Luiz Fernando Bertolucci)
See the following URL that is a demonstration of muscle repositioning.

Muscle Repositioning (MR) is a different form of myofascial release came out of work of physiatrist Bertolucci LF. The term Muscle Repositioning was also coined by him.

The techniques start by twisting of fascia around harder structures that result in unification of body segments into a single block, a phenomenon that is possible immediate visual surveillance during & after the treatment.

Salient points of Practice:
1. Generally the practitioner produces small shaking movements on the client’s body.

2. Linkage of body parts leads to a unique sense of firmness under the practitioner’s hands. Once connected to the sensation of firmness, the maneuvers then proceed, up to a point in which a release naturally takes place (Compare Bind versus Release).

Old explanations & new challenges:
The older explanation of release of the bind or firmness was thought to be a mechanical phenomenon. The mechanical explanation says twisting of fascias would produce its tensioning, which, by its turn, would compress the joints and unite the segments that lie between them.

Such interpretation may be accurate, but more than pure mechanics seems to be taking place. If the contact with the sense of firmness is accurate and long enough, another class of phenomena follows: the client often begins to show involuntary motor reactions such as following:

i. Progressive isometric activity of the cervical erectors (most outstanding observation as well as palpation finding present in the neck in all subjects). It can be felt by the practitioner as an involuntary pushing of the client’s head cephalad and backwards but when this reaction is strong enough then one can see and palpate the muscular activity.

ii. Other involuntary concurrences are also observed. They are horizontal eyes movements, clonic and tonic appendicular movements and tremors.

How Bertolucci explains it? (The Hypothesis)
1. This form of manual therapy may be stimulating neurological reactions. (EMG activity in the local & area away from the immediate recipient area shows reactions in the neck in all subjects tested, abdominal activity during a maneuver in the thoracic area).

2. Firmer the feel to the clinician’s hand, the higher the EMG signals i.e.: the degree of firmness is possibly related to the intensity of the tonic reaction.

3. It is also noted that firmer the feeling to the touch, the more effective the maneuver.

Hence it is supposed that clinical efficacy of the maneuvers is related to the tonic reactions (a sort of neural reflex) during the clinical practice is a desired clinical effect.

Patients feeling of the maneuver:
Muscle repositioning is not only a clinician’s feeling only. Rather there is a matching of sensations experienced in both client and practitioner.
Once the sense of firmness is achieved, a whole class of sensations simultaneously emerges in the clients such as:

i. a sense of connectedness among structural segments
ii. a sense of bipolar expansion in the body’s longitudinal axis, among other sensations.

Recommendations of Bertolucci:
1. To elicit proper responses approach the soft tissues in an oblique angle.
2. A force couple is formed by oblique force mentioned above & inertia of the bodily segments under treatment.
3. The resultant force of the above said force couple produces internal shear forces among musculoskeletal structures in very precise directions. Which further result in a clear sensation of relative movements among myofascial compartments.

According to Bertolucci the feeling of muscle repositioning resembles the surgical maneuver named blunt dissection. Sometimes it is even possible to pinpoint the cleavage lines between fascial planes engaged in a certain maneuver. This approach may possibly change the relative muscle positions, directly affecting the myofascial force transmission as described by Huijing and colleagues.


1. J Bodyw Mov Ther. 2008 Jul;12(3):213-24. Epub 2008 Jul 7.

Tuesday, July 14, 2009

Do we really require nutritional suppliments in training?

Your coaches lie to you.

you do not require any supplement just because all supplement you take comes in your food. if the caloric requirement is more, the increase of it (calories & proteins. fruits & vegetables) in a balanced way assures a adequate intake of all the nutrients. renowned researchers in exercise physiology & nutrition sciences (Katch & Mcardle) refute the idea of taking supplements in training.

More to it you can not assess the deficiency of particular nutrient (that you take as supplement) in common laboratory conditions. Toxic levels too occur with high intakes. However generally the nutrient requirement is in a vary wide range. That means one can tolerate increased nutrients as supplements in a wide range which does not mean that we require it more than a adequate level. More than adequate range do not also mean a high training output or competitive result or augmented health.

Following are self-explanatory terms associated with nutrient requirements.

Please note the following

• EAR: Estimated Average Requirements
• RDI: Reference Daily Intake (Please refer to ICMR guideline, 1991- NIN, Hyderabad)
• AI: Adequate Intake
• UL: Tolerable upper intake levels

Sunday, July 12, 2009

Do any study support “Manual therapy lead to adjustments & that is responsible for it’s therapeutic effects” ?

Many authors & researchers claim & have demonstrated that therapeutic effects of manual therapy are due to pain modeling via sensory inputs through their well designed researches. But many clinicians believe that manual therapy lead to subtle bony adjustments which leads to it’s therapeutic effects. However, it is not well demonstrated that adjustments occurs in such cases.

This following paper by Keller & colleagues is one among the many papers that indicates but do not clearly demonstrate the potential mechanical adjustments by manual therapy. The experiment was carried out on a replica (model) of the spine & model validity was determined which showed good agreement with in vivo human studies.

This study reveals following:
1. Quasi-static and low-frequency (<2.0 Hz) forces at L3 produced L3 segmental and L3-L4 inter-segmental displacements up to 8.1 mm and 3.0 mm, respectively.
2. Impulsive forces (Such as used in HVLA manipulative techniques) produced much lower segmental displacements in comparison to static and oscillatory forces.
3. Differences in inter-segmental displacements resulting from impulsive, static, and oscillatory forces were much less remarkable (all techniques may result in similar outcomes!!!).

The latter suggests that intersegmental motions produced by spinal manipulation may play a prominent role in eliciting therapeutic responses.


Keller TS et al; J Manipulative Physiol Ther. 2002 Oct; 25(8):485-96.

Friday, July 3, 2009


There is increase in PA spine stiffness during voluntary contraction of the lumbar extensor muscles. PA dynamic spinal stiffness at rest and during lumbar isotonic extension tasks ware studied by Colloca & colleagues (2004) in patients with low back by a dynamic mechanical impedance study.

About the study:

13 patients with LBP underwent a dynamic spinal stiffness assessment in the prone-resting position and again during lumbar extensor efforts. Same measurements are taken after PA manipulative thrusts (approximately 150 N, <5 milliseconds) over L3 spinous & transverse processes with the patients at rest and again during prone-lying lumbar isotonic extension tasks.

Dynamic spinal stiffness characteristics revealed that

1. A significant increase in the PA dynamic spinal stiffness was noted for thrusts over spinous process during isotonic trunk extension tasks compared with prone resting.

2. But no significant changes were noted for the same measures over the transverse processes.

This study suggest in trunk extension tasks normally the spine stabilization occurs by the paraspinal muscles any PA force to the central spinal area only increase the effort of stabilization by these muscles. Colloca & colleagues concluded that the trunk musculature and spinal posture plays a predominate role in providing spinal stability.


Colloca CJ et al; J Manipulative Physiol Ther. 2004 May;27(4):229-37.

Effect of SPAM (spinal posteroanterior mobilization) in asymptomatic subjects

SPAM includes commonly applied forces of low-frequency sinusoidal oscillations (<2 Hz) as used in mobilization. Despite the reliance on these techniques in clinical practice, there is little scientific evidence to substantiate their use. Before progress in this area can be made, it is necessary to characterize the forces used during typical mobilization procedures.

Spinal mobilization is usually applied to
1. modulates pain
2. improve mobility of a stiff segment
3. finally, to assess the condition

However these benefits are marked in the subject suffering from mechanical spine disorders. Fundamental to this concept is the belief that spinal mobilization will influence the mechanical properties of the symptomatic motion segment. Nothing is known about what are the effects of SPAM in asymptomatic subjects.

Using proper control methods trained physiotherapist applied the standardized PA mobilization technique to L1, L3 & L5 spinous process for two minutes. The mean force of 146 N (standard deviation = 8 N) at a frequency of 1.5 Hz was applied. It was found that SPAM has no segmental effect on spinal PA stiffness (1).

Discussion: This paper of Allison & colleagues questions “Which mechanisms contribute to the changes that occur after PA spinal mobilization?” However Nathan & colleagues in 1994 found low force, PA impulses produce measurable segmental motions and reinforce the notion that mechanical processes play an important role in spinal manipulation and mobilization.


1. Allison G et al; Physiother Res Int. 2001;6(3):145-56.

2. Nathan M et al; J Manipulative Physiol Ther. 1994 Sep;17(7):431-41.

Wednesday, July 1, 2009

Functional radiography (Cineradiography) of the Lumbar spine: Biomechanical implications for treatment

A part of my review for a journal..................

Functional radiography or Cineradiography refers to radiography in the time course of the movement. Spine Cineradiography reveals many interesting aspects of stable (normal) & unstable (lysthetic) spine.

I. Normal spine flexion-extension kinesis

During flexion, initial lumbar motion starts stepwise from the upper level to the lower levels with phase lags. Angular velocity at the onset of motion increases as the level descended. On the contrary, during extension, initial motion started from the lower level (L5/S1) to the upper levels. There is no relation between velocity and spinal levels during backward flexion. Through out the F-E excursion there is a harmonious relation between the angular motion and translatory motion of the motion segment (10).

The motion profiles at L5/S1 were different between flexions & extension (11). In extension, motions in upper lumbar segments were small, and the L5-S1 segmental motion only contributed to the total lower lumbar motion (12).

What is phase lag?

The lumbar and lumbosacral segmental motions do not occur simultaneously but stepwise from the upper level with intersegmental motion lags during flexion. For example during lumbar spine flexion L4-L5 segmental motion is delayed from the L3-L4 motion by an average of 6 degrees and preceded the L5-S1 motion by an average of 8 degrees (12).

Normal spine & hip kinesis

Investigation of relation between the lumbar motion and hip joint motion reveal the lumbar motion preceded the hip flexion in forward bending and delayed from extension of the hip joints in backward bending.

II. Lysthetic spine flexion-extension kinesis

Lumbar kinesis study (10) of degenerative spondylolysthesis (L4 over L5) reveals

1. Forward Lysthesis less than 15% shows disharmonious angular motion & translatory motion in the lysthetic motion segment. The angular motion is large but translatory motion is moderately reduced.

2. Forward Lysthesis more than 15% also shows disharmonious angular motion & translatory motion in the lysthetic motion segment. The angular motion is moderately restricted but translatory motion is largely reduced.

3. While extending from flexion in patients with less than 15% slippage show large angulations and disordered motion pattern which is caused by segmental instability. While in patients with more than 15% slippage show decreased translation and disordered motion pattern during flexion is caused by restabilization.


10. Takayanagi K et al; Spine. 2001 Sep 1;26(17):1858-65.

11. Harada M et al; Spine. 2000 Aug 1;25(15):1932-7.

12. Kanayama M et al; Spine. 1996 Jun 15;21(12):1416-22.