The essay deals with the joint anatomy of the Lumbar facet joint. A condition called the facet joint arthritis/ lumbar spine osteoarthritis associated with lumbar face joints is discussed. Further, the essay analyses the efficacy of the technique called joint mobilisation for use as treatment for facet joint syndrome. The incorporation of the treatment technique in field of Clinical Myotherapy and its relevance is also discussed.
The joints in the spine region are called as facet joints. These joints function as a unit and involve complex structures to facilitate functional segmental movements. The facet joints have complex involving the facet joint capsule, articulating facets, multifidus muscle, and ligamentum flavum. These joints are categorised as Type I or Type II based on the presence of the subcapsular pocket, that are common in the superior curving fibers of the joint capsules as well as the inferior curving fibres. The facet joints also known as the zygapophysial joints are the synovial joints between the two adjacent vertebrae in their articular processes. Facet joints are hinge like structure that are connecting link between the vertebrae together behind the spine. Each facet joint is encapsulated in the connective tissue and lubricates the joints by producing the fluid called synovial fluid. Therefore, they are also called as synovial fluid. It is because of this lubricating function that they facilitate twisting, flexion and extension motion of the joints (Varlotta et al., 2011). In the each spinal motion segment there are two facet joints and are encompassed by the meningeal nerves. The facet joints in the lumbar spine are known as the lumbar facet joints. The role of the each pair of joints is to control the movement of the spinal segment. In the lumbar spine the facet joints protect the motion segment from flexion, excessive rotation, and anterior shear forces. However, the facet joints have little influence over the lateral flexion. In the lumbar spine the facet joint is aligned in the way that there is limited rotation. Both the superior and the inferior facets are aligned to allow for extension and flexion. The vertical movement of facets during flexion and extension involves the interplay of superior, inferior fibres and the subcapsular pockets in the join capsule. Tension limits the flexion and there is less tension by the superior fibres during the extension. The posterior joint capsule covered by the tendons of the multifidus muscle running the lateral and vertical direction forming thick layer of connective tissue of facet joint capsule on the posterior aspect which reinforces the posterior capsule (Gorniak & Conrad, 2015).
The function of the facet joint can be disturbed by the facture, degeneration, dislocation, injury, instability from trauma, surgery, and osteoarthritis. Osteoarthritis of the lumbar facet joints occurs due to disturbance of all the components of the joint complex. For, this essay the joint condition to be focused is osteoarthritis. The osteoarthritis of the lower lumbar facet joints manifest as the lower back pain. The osteoarthritis of the lumbar fact joints is common in the age 1-9 and the prevalence increases in the people of this age group (Netzer et al., 2018). A varying degrees of the Facet Joint Arthritis is reported among older adults aged 65 years and above (89% -95% of individuals). The most common seen are the L4-5 and L5-S1 (Suri et al., 2013). This condition is caused by the pressure overload on the fact joints, ageing, and major injury. The capsule having the collagen fibre arrangement only permits motion in one and limits in other direction. The dysfunctional movements of the joints are the results of the excessive joint articular cartilage wear. The capsule limits the motion due to excess tightness and exerts the force on the joint surfaces. It is the cause of the joint pain and the excess articular surface wear. The abnormal motion is caused by the torn capsules, producing articular damage. Degeneration of the intervertebral disc creates pressure on the joints due to compromise of the lumbar fact joint complex. Due to degeneracy and wear and tear process the joints begin to collapse which decreases then space between each vertebrae. The facet joint arthritis result in increased loading and wear on the facet articular surface. Consequently, it damages the way the facets are lined up creating excess pressure on the articular cartilage layer of the facets. During the progress of the arthritis, the synovial fluid lubricating the joints is damaged. It causes the rubbing of the bone against each other. The facet joints then show spurring of the bones that press against the nerve root. It may extend upto the spinal canal to cause the spinal stenosis. The pain during arthritis is originating from the lumbar facer joint s known as the facet joint syndrome and spinal arthritis. The pain may radiate to hips, buttocks, thighs and groins, (Gorniak & Conrad, 2015). In conclusion, the overall limiting movement is associated with the lumbar facet movements, pressure on the capsule and joint surfaces and limited motion by capsule. In osteoarthritis capsule narrows down, and the degeneration in lumbar facets leads to limited mobility (Netzer et al., 2018).
The symptoms of the lumbar facet arthritis manifest as the difficult bending, and twisting of the spine and in lower back it manifest as the difficulty in straightening the back or getting up from chair. The symptoms in the legs, buttocks and feet may be because of the nerves in the lumbar spine. The facet joint syndrome comes with the numbness, pain and muscle weakness and affects the various parts of the body (Suri et al., 2013). There are various treatments recommended for lumbar facet joint syndrome or osteoarthritis. The most common interventions are the physical therapy (Manchikanti et al., 2018). The centre of the discussion in this regard is chosen to be joint mobilization. It is the manual therapy intervention performed by the physiotherapists targeted at the synovial joint with the passive movement of the skeletal joints at low velocity within or at the limit of joint range of motion. Therapeutic effect is the aim of this intervention that is to have the pain free joint motion at normal range. The therapeutic effect of the joint mobilisation technique also known as spinal mobilisation is due to pain reduction by modulation of the nervous tissue. It increases the joint motion. Over years, the joint mobilisation techniques have certainly improved. It is recommended as treatment technique in many guidelines of the osteoarthritis (Courtney et al., 2016, Kisner, Colby & Borstad, 2017). The subsequent section would discuss the effectiveness of joint mobilisation as the treatment technique for facet joint syndrome, along with the techniques that would be effective.
As per several randomised control trial results passive joint mobilization in patients with knee osteoarthritis results in reduction of pain. Various techniques include Lumbar spine rotation mobilisation with straight leg raise, Lumbar rotation mobilisation, Mulligan lower back self-mobilization exercises, and others. When comparing the joint mobilization technique with the placebo ultrasound it was found that there was great improvement in the group of patients with the lumbar facet osteoarthritis undergoing the manual therapy and the improvement lasted for one year (French et al., 2011). It is also argued that when the joint mobilisation and the exercise program were compared to home exercise interventions, there was improvement in the function of the joints and the pain, where the results were significant (LYN, 2011). The results are congruent with the experimental laboratory study by Courtney et al. (2016), which examined the effect of the joint mobilization on impaired conditioned pain modulation or CPM. The results showed enhancement in the CPM following joint mobilization..It works in patients with lumbar facet syndrome and spinal arthritis, through enhancement of descending pain.
The Maitland mobilization technique is used to relive patient from stiffness and low back pain caused by lumbar facet arthritis. In this technique, the mobilisation creates the movement within the spine to reduce stiffness and lumbar facet joint pain. Mobilisation technique with Mulligan concept is used. In this case, the mobilisation with movement is used to increase the flexion of the lumbar facet joint. In one technique called the posteroanterior mobilisation technique, force is applied on the vertebral segment in a posterioanterior direction to reduce pain in facet joint syndrome and increased range of motion of lumbar extension. Beselga et al. (2016) studied the efficacy of the “Mulligan’s mobilization with movement technique on dorsiflexion and pain” in patients with lumbar facet osteoarthritis. This technique is based on application of sustained accessory mobilization and an active physiological movement. These results are congruent with that of Rao et al. (2017), which showed the equal efficacy of the “Maitland mobilization and Mulligan MWM,” in reducing pain in the osteoarthritis patients. It was also effective in improving the functional mobility. Unlike the MWM, the Maitland technique is applied on the on the spinal joints.
Myotherapy is the manual approach scientifically integrated for treating the painful muscle pathology, and pain originating from the muscular origin. It is the branch of manual therapy and similar to physiotherapy. Traditionally, myotherapist are known for strong focus on use of joint mobilisation techniques along with the myofascial release, and soft tissue techniques. These techniques are useful for cases where the limited range of motion, pain and reduced functions are the part of the picture (Nagata et al., 1997; Guymer et al., 2012). There are evidences overall for the use of joint mobilization in physiotherapy for broad range of ailments. Clinical myotherapists unlike the myotherapist perform range of techniques and also play role of manual physiotherapist and have extensive knowledge of the “anatomy, physiology, clinical assessment and injury management” (Yang et al., 2018; Vázquez Delgado et al., 2010; Kogo & Kurosawa, 2010). Among variety of modalities such as manual therapy, joint mobilisation technique is just the part of the process. Moreover, joint mobilisation technique is relevant for the clinical myotherapy, as the professionals are acquainted with the fundamental of the pain management and its physiological aspects. Clinical myotherapist have the knowledge and skills to design individually tailored treatment regimes as they address the pathological process involved in the disease state. It is because the treatment commence through various joint tests. It cannot be decided at the present as to which joint mobilization techniques would be completely relevant in the Clinical Myotherapy for treating the osteoarthritis patients, as there is less literature evidence (Hage, 2017).
Clinical myotherapist care known to provide integrated therapeutic care, as they can use different therapeutic modalities to relive both the chronic and acute pain. They achieve desired outcome for clients by using range of techniques that align with the techniques of physiotherapist. Using joint mobilisation technique with other pain management technique clinical myotherapist can provide optimal care for lumbar facet arthritis. Myotherapy focuses solely on the musculoskeletal pain, osteopathy on structure, physiotherapy on movement (Baster, 2015). Although it is evident from the randomised control trials that the above mentioned joint mobilisation techniques are effective, there is need of further research for concluding evidence for use by clinical myotherapist. There is rich literature about the spinal mobilisation technique used by clinical myotherapist and physiotherapist. It is not clear as to which techniques are effective for different symptoms of lumbar facet osteoarthritis in different body regions. On the other hand, the research evidence on the side effects of the joint mobilisation technique is very less. It means that joint mobilisation technique is very safe indicating its relevance in the clinical myotherapy (Hage, 2017).
The essay has highlighted the anatomy o the lumbar facet joints and discussed with evidence the commonly associated condition called osteoarthritis. Effectiveness of joint mobilisation as a treatment technique for osteoarthritis is described in easy explicitly. It can be well incorporated in the field of clinical Myotherapy. However, there is lack of sufficient concluding evidence on the complete efficacy of the joint mobilisation technique for treatment of osteoarthritis. There is need of further research in this area for complete integration of the technique in clinical myotherapy for osteoarthritis.
References
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