#PTonICE Daily Show – Tuesday, September 19th, 2023 – Mobilization with movement to improve lumbar flexion

In today’s episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan discusses a mobilization technique specifically designed for patients with unilateral symptoms. These patients experience tightness primarily on one side of their body and often feel the need to be stretched out, especially in the morning.

To address these issues, Zac introduces the concept of mobilization with movement. This technique involves actively moving the affected area while applying a mobilization force, with the goal of improving symptoms and increasing range of motion. Zac then demonstrates a mobilization technique using cups. He explains that the cups will be placed on the region of the patient’s back that is most tight or painful. The patient is then instructed to keep the cups on for about a minute, allowing them to acclimate to the sensation.

It is important to note that this mobilization technique may not be suitable for all cases of back pain. Back pain can manifest in various ways, and it is crucial to have the right patient in front of you for this technique to be effective. However, if the patient experiences improvement when they forward bend and their symptoms feel better during this movement, the mobilization with movement technique can be beneficial.

Zac  suggests starting with easy active range of motion exercises and gradually adding more stimulus, such as overpressure or the use of weights. He highlights the versatility of this technique and mention that he frequently uses it in the clinic for patients with similar presentations.

Take a listen or check out the episode transcription below.

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00:00 INTRO

Good morning PT on Ice Daily Show. Zac Morgan here. I’m a division lead with the spine division, so you can find me on the road teaching either the cervical spine management course or the lumbar spine management course alongside of Jordan Berry and now Brian Melrose. Speaking on that spine topic before we jump into this morning’s Technique Tuesday, I wanted to just point out the next handful of courses that we have. So we actually have three different lumbar course offerings this weekend. So last minute you want to jump in, we’ll be in Richmond, Virginia. Baton Rouge, Louisiana, and then Denver, Colorado. So if you’re looking for a last second seat there for lumbar spine, jump into those. If none of those work, we have a few more offerings this year. So in October, the 21st and 22nd will be Frederick, Maryland. So right outside of the DC area there at Onward Frederick. Also have Fort Worth, Texas, the November 4th, 5th weekend, and then December 2nd and 3rd at Onward Charlotte. I have a lumbar course as well. Quickly, just pointing out the cervical ones, and then we’ll jump into the content. Greenville, South Carolina, October 14th and 15th. Bridgewater, Massachusetts, that’s November 11th and 12th. And then here in Hendersonville, December 2nd and 3rd. So those are the cervical and lumbar offerings left this year. But without further ado, let’s kind of jump into the topic this morning.


So this morning I want to kind of bring back Technique Tuesday in the Spine Division. If you’ve been around forever, like myself, you remember those days way back in the day where Jeff was in his clinic there in Upper Michigan showing some different techniques each Tuesday morning. And those were always really fun to consume because it just gave you some new ideas and things to play with. in the clinic and this morning I wanted to cover a technique that doesn’t live in our lumbar course but it is one that I find myself using from time to time. But before we actually jump in and do the technique I’d like to kind of describe who I would do this to because in particular this is a technique that you want to have the right patient selection for. If you’ve been to the lumbar course, you’ve heard the stories of derangement and dysfunction. If you’re McKenzie trained, you may be really familiar with those terms as well. If you’re not familiar, go back a few months to where I did a PT on ice kind of covering these topics about the lumbar spine needs to flex, and that’ll kind of refresh you or jump in the live course if it’s all completely blank to you. But essentially, technique selection for the right patient is huge here. So what we’re looking for is the patient who does have their symptom onset when they flex forward or when they bend forward, they feel their symptoms, but the response to that flexion is the important part. So we’re looking for that dysfunction patient or soft tissue extensibility dysfunction, however you like to think of that. McKenzie coined that term dysfunction and essentially the idea being that the soft tissues living on the backside of the spine are not extensible enough and then when the person bends forward and they reach the limit of that extensibility they receive their symptoms. So the real key in diagnosing this person is their response to the flexion. Because if you’ve been around for a while, if you’ve seen patients presenting with low back pain, you know that for some folks, when they move into their symptoms, they get tremendously worse. If that is your person in front of you, each time you have them flex, they feel worse, or they lose range of motion, or perhaps even peripheralize symptoms down their limb, that is not who you would do this technique to. Rather, the inverse should be true. So on your active range of motion exam, this patient’s gonna come in, and they’re gonna present with back pain, Sometimes they might have some leg symptoms, but more commonly back, buttock pain. And you’re gonna have them bend forward, and when they bend forward, they’ll say, oh Zach, that’s my symptoms, I can feel it right there. And often if you observe their lumbar curve while they’re forward bending, you’ll notice this person does not have that nice reversal of the lumbar lordosis. As a matter of fact, they’ll often hold their lumbar spine very rigid as they move forward. So their back will stay completely flat, and they’ll just move into hip flexion. Now the key is that you have to have them do that multiple times. So if you have them go ahead and follow up with another rep, what you should see if the patient’s a dysfunction patient would be definitely no worsening, but probably more often a bit of improvement. Whereas the derangement patient worsens every time they flex. This person feels a bit better each time you move them into the provocative motion. So for that, we want to treat that with repetitive flexion. So this person needs to restore their lumbar flexion and we’re here to help them. So homework often is going to be simple flexion, like just get in a position, flex your back regularly. You can go with a typical McKenzie dosage of 10 reps an hour. You know here at ICE we make those decisions based off of that person’s irritability, both psychological and physical. And so dosage is going to play a lot into their irritability. But one technique that I love for this patient is a mobilization with movement into lumbar flexion. Now we see this patient a ton at our clinic because this, you’ll see this presentation show up quite a bit with weightlifters. So weightlifters will often have some sort of a flexion injury at some point and then they’ll quit flexing their back. So they’ll maintain neutral and often they’ll even hyperextend a bit to maintain neutral in their back. But one thing’s for sure, they will not allow their back to flex. And as with anything in the body, if you don’t use it, you lose it. And so over time, this person develops a lot of stiffness and tightness in their back. They have a lot of complaints like that, and they have a really hard time forward bending. The odd part is the solution again is to forward bend. So in homework, I’m going to have them do that in life. Whether that looks like a cannonball position, repetitive standing flexion, it doesn’t really matter so much. But one thing I love doing in the clinic is this mobilization with movement. So shout out to Brian Mulligan who kind of conceptualized mobilizations with movements, snags, nags, huge kind of founder in the manual therapy world and really responsible for kind of giving us some of these techniques. But this is one in particular that I find myself using quite a bit. And I actually have a really good patient here in front of you. So I’m gonna have Alexis step in. If you don’t know Alexis, she’s my wife, better half, and then also faculty in our pregnancy and postpartum course. So Alexis has this problem. She has a really hard time flexing her back. It’s typically pretty bad here in the morning, so now is a pretty good time for us to be doing this.


But essentially what you want to do for this mobilization with movement, confirm it’s on the right patient, then have them sit on a table. In general, I would probably bring up the table up a little bit, but this will work. It really doesn’t matter if you have a massage table or a high-low. This one’s super easy to do. The only item you need is a mobilization belt. and it doesn’t really matter so much which one, but I kind of like this blue one for a couple reasons. It’s cheap. Um, so this is the Mulligan belt and then it doesn’t have that big leather piece that sort of gets in the way for this mobilization and it costs extra that you don’t need. So what you’re going to do is form a big loop with that mobilization band. So make sure it’s in a big loop and it’s going to go around you and the patient. So put it around your back first. And then you’re going to reach around the patient, clip, make sure that buckle’s not contacting them. And then the belt should live right at their ASIS. So you want that belt to be essentially where like the waist part of a seat belt would be on an airplane or in the car, right at the ASIS. Then I’m going to tighten that up to where I’ve, right now I’ve got way too much slack in the belt. So I’m going to put, this to where we now have it taut, so it is nice and firm. And essentially what I’m thinking about with the belt is fixing her pelvis to this table. So you can see it’s at a little bit of a downward angle. not completely parallel. If I was completely parallel, I’d be pulling Alexis back towards me. I want this downward angle with the belt to kind of fix the pelvis down to the table. From here, the mobilization is super easy and simple. Sometimes I’ll start out without even mobilizing, but just fix the pelvis and then have the patient move through some active range of motion and deflection. So what Alexis is doing is she’s just reaching her fingertips towards her toe here, trying to allow this part of her low back to really relax. and just move forward. So typically this is how I would start someone out here. Rather than cranking on them immediately, I’ll just allow them to access whatever flexion they feel comfortable with and just move forward. And you know at ICE we like to pump. So we’re usually going pressure on, pressure off. We’re hitting that in range position and then coming out. Let’s say 10 or so reps have gone by and she’s continuing to improve each time we do this. She likes the feeling of the stretch. That’s where I’m going to add my pressure or my mobilization force. Now I’ve seen this technique taught segmentally specific where you find the exact segment that you feel is reproducing the patient’s symptoms and drive on that. But I’ll be honest with you all. I’m typically not the guy that’s in there with my thumbs on a specific segment. Rather, I use my whole hand to give nice broad force. If the problem’s in their thoracolumbar junction, my hands are typically right here around the bottom of the ribcage, pushing forward. But, go ahead and come on up. If the problem’s a little bit lower in the lumbar spine, my hands are just gonna live a little bit lower. So I’m not putting any segmental pressure here. What I am doing is just essentially pushing into flexion in the region of the back that I feel is provoking the symptoms. So don’t overthink your mobilization force. Just very gently add pressure all the way to in range and then come off. Super, super simple. I find just as much success being very regional as I do being very segmentally specific. So don’t overthink this one. This is just repetitive motions with overpressure. Very nice way to loosen up the lumbar spine. typically this patient loves it.


Now a couple little nuances here with this technique before we finish up. Sometimes you’re going to have a patient who is more of a unilateral restriction. So they’re going to mostly complain of right-sided back pain and it’s going to be mostly tight on their right side but not so much on their left side. For that person, you want them to forward bend and reach to the left. You want all of these tissues to open up. So Alexis is now forward bending and grabbing her left ankle, and you can see that that would open up this side, and it gives you the really nice ability to just kind of push and open up kind of that QL, all of the lumbar extensors, everything sort of living on this side of the back. So for those more unilateral restrictions, come on out, She’s liking that position, that’s why she’s hanging out there so long. For that unilateral presentation, sometimes I’ll do this mobilization a bit unilaterally as well, but just some nuances that you can play with.


The last piece that I wanted to show you all is just a way to increase the vigor a little bit, and kind of give the patient that perceived stretch, because often this person is gonna tell you, when they wake up in the morning, I feel really tight, and I feel like I need to be stretched out. And so we want to kind of match that feeling So for that I want to expose their back a little bit and I’m going to add some cupping. So what I’ll do with cupping is I’ll kind of take my cups, find the region that seems the most tight or painful to the patient, and then I’ll fix these cups on them, have them hang out with the cups on. I’m not gonna do that on the video, but for a minute or so, just to sort of acclimate to having these on their back. And then after a minute or so goes by, they’re gonna move through those same flexions with the cups on. So I’ll show you real briefly just a couple of those. Always use a little cream when you’re using cups. It’s much friendlier. to your patient. But essentially what we’re going to do is fix that cup on her back. That already gives her a bit of a sensation of stretch. These are over the lumbar extensors and they’re in the region that’s been provoking her symptoms, the region she feels the most tight. Now again, a minute or so would go by. We would make sure she felt relatively comfortable here. with the cups on before we moved, but let’s say that minute has passed and I’m ready to go ahead and move through some more range of motion. The cups are still on. Now my belt is in the exact same position and Alexis is doing the very same thing. So she’s just forward bending. I can even add some more pressure if I like, or I could slide these cups around and see if I could isolate the exact area that feels the most stiff. appreciate that this is definitely a higher vigor than where we started with. So you want that person to have lower irritability at this point. You want to have seen some good symptom response prior to progressing to this much vigor. But if you’re seeing good success and you want to up the vigor here, cups are a really nice way to increase the stretch to that region. So in summary, No one technique is good for all back pain. Back pain presents a bunch of different ways, and you’ve got to have the right person in front of you if you expect it to work. So for this technique, if the person improves each time they forward bend, their symptoms feel a bit better when they move into them. you want to move into those symptoms with your treatment, and that’s where this mobilization with movement is really helpful. You can start out really easy with just active range of motion. You can then add some overpressure. If you want even more stimulus, you could add some cups, or better yet, even have them hold a weight in front of them and have that weight drag them down. Lots of creative options here with this mobilization with movement, and just one that I find myself using quite a bit as we see an awful lot of folks who have this dysfunction presentation. Team, hope to see you on the road at some point. We are out and about a bunch throughout the rest of this year. Jump on ptonice.com and jump into any of the live courses that are in your area or ones that are on your list. Keep your eyes peeled for future announcements with ICE. Lots of cool things on the docket coming out here in October. So I will see you again here soon in a month. Until next time, hit that mobilization with movement.

14:29 OUTRO

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