CLEARING TEACHER THERAPY FLEXIBILITY EXERCISE EXERCISE
2.1 Definition of Flexibility Many experts define flexibility. Flexibility is the ability of various joints of the body to move through their full range of joint motion (in Nugraha, 2013). Meanwhile, Flexibility exercise is a useful exercise to increase flexibility so that the joint muscles are not stiff and can move freely without significant interference. With adequate flexibility a person can carry out a task of movement with adequate performance, therefore flexibility is an important element of physical fitness related to health and also physical fitness related to performance (Rusli Lutan, et al, 2003). 2.1.1 Types of Flexibility There are several types of flexibility that are known. According to Kurz (in Appleton, 2009), there are three types of flexibility, namely: a. Dynamic flexibility. Dynamic flexibility, also called kinetic flexibility, is the ability of muscles to carry out dynamic movements in bringing limbs to move to full joint motion. dynamic flexibility can be trained with dynamic stretching which is usually done by moving rhythmic body movements or limbs with circular movements or bouncing limbs so that the muscles feel stretched, to gradually increase progressively the joint motion . b. Static-active flexibility Stability-active flexibility, also called active flexibility, is the ability to start and maintain a position using only the tension of the agonist and synergistic muscle groups when the antagonist muscle is stretched. c. Static-passive flexibility Stability-passive flexibility, also called passive flexibility, is the ability to start a movement and maintain a position using body weight, limb assistance or external assistance. Static flexibility can be trained with stretching exercises that are often done before and after doing activities Sports. 2.1.2 Factors that affect Flexibility Each individual has different flexibility. The difference in body flexibility ability is influenced by several internal and external factors. According to Bompa quoted by Ibrahim (2009), flexibility depends on the structure of the joint, the muscles that pass through the joint, age, sex, body temperature, muscle tone, muscle strength, fatigue and emotions. According to Fox (1993) (in Airlambang, 2001) explains that the factors that affect flexibility are: a. Structure of joints and body tissues. The structure of the joints and body tissues referred to in this case are the bones, muscles that pass through the joints, ligaments, joint capsules, and discs. Healthy bone structure will facilitate joint movement to achieve maximum scope of joint motion. Muscle mass that is too large can also inhibit joint movement. b. Psychic state. Someone who is not motivated or who has mental disorders, it is difficult to get the flexibility he actually has. c. Age. As we get older, flexibility will decrease. Conditions for bone structure and joints in old age will change and not as good as in young age. Changes in the musculoskeletal system due to physiological aging processes such as changes in collagen, degeneration, erosion and calcification of the cartilage and joint capsules, and a decrease in the functional strength of the muscles causing the joint to lose flexibility so that the area of joint motion is reduced. d. Gender. Normally, women tend to be more flexible than men. However, women also tend to have more problems with flexibility. This is caused by lifestyle, life cycle as a woman, and as a result of increasing age. e. Sports activities. Sports activity is an external factor that affects the flexibility of the body. Individuals who exercise regularly will have better flexibility compared to individuals who have never done sports. Lack of exercise can cause the flexibility of the connective tissue to be unfavorable so that the muscles and ligaments easily become sprain (Caillet, 1991). In addition to those described above, there are factors that also affect the results of the measurement of flexibility, namely the Body Mass Index (BMI). Body mass index has a strong correlation with body fat (body fatness). The accumulation of fat in certain body parts such as in the abdomen and waist will be a barrier to the occurrence of flexion movements of the lumbar. Besides biomechanically, body weight will affect the pressure or compression of the lumbar spine when doing forward flexion movements, so that it will affect the measurement results of its tendency to decrease (Purnama, 2007). 2.2 Lumbar Anatomy and Physiology 2.2.1 Lumbar Anatomy Anatomy of the Spinal Spine is medically known as the vertebral columna (Malcolm, 2002). The spinal sequence is a flexible structure formed by a number of bones called vertebrae or vertebrae. Between every two vertebrae there are cartilage pads. The length of the spinal sequence in adults reaches 57 to 67 centimeters. In total there are 33 bone segments, 24 of which are separate bones and the remaining 9 segments are later fused into 5 sacrums and 4 pieces of religious (Pearce, 2006). The vertebrae are complex structures that are broadly divided into 2 parts. The anterior part is composed of the vertebral body, the intervertebral discs (as articulation), and is supported by the anterior and posterior longitudinale ligaments. The posterior part is composed of the pedicles, laminae, vertebral canals, and the transverse and spinous processes that house the supporting and protective muscles of the vertebral column. The posterior part of the vertebrae is connected to one apofisial (facet) joint. The stability of the vertebrae depends on the integrity of the vertebral bodies and the intervertebral discs as well as the two types of supporting tissues namely the ligament (passive) and the muscle (active) (Pearce, 2006). Vertebrae are grouped and named according to the area they occupy, namely: a. Cervical Vertebra Cervical vertebra consists of seven bones or vertebrae of the neck, vertebrae are the smallest. Neck bones in general have the characteristics of a small and rectangular body, longer to the side than forwards or backwards. Large arches, spinous processes or two ends of thorns or bividas. Transversal processes or pore wings with holes due to many foramina for the passage of the vertebral arteries (Pearce, 2006). b. Thoracic Vertebrae The thoracic vertebrae consist of twelve bones or other names of the vertebrae larger than the cervical ones and the lower ones become larger. Its characteristics are its oval-shaped body with facets or small indentations on each side to connect the ribs, the curvature is rather small, the thorns are long and pointing downward, while the wing tides that help support the ribs are thick and strong and contain joint facets for ribs (Pearce, 2006 ). c. Lumbar Vertebrae The lumbar vetebra consists of five vertebrae or other names are the lumbar vertebrae, the lumbar bone area is the largest. The thorns are broad and shaped like a small ax. Its wingspan is long and slim. The fifth segment forms joints and sacrums in the sacral lumbo joints (Pearce, 2006). d. Sacral Vertebrae The sacral vertebra consists of five bone segments or other names is the groin bone. The crotch is triangular in shape and is located at the bottom of the vertebral column, sandwiched between the two inominata bones. The base of the sacrum is located above and jointed with the fifth lumbar vertebra and forms a characteristic intervertebral joint. But anteriorly from the sacrum base forms the sacral promontorium. The sacral canal is located beneath the vertebral canal. The walls of the sacral canal are hollow for the sacral nerves to pass through. Thorns can be seen in the posterior and sacral views. e. Vertebral Kosigeus Vertebral Kosigeus is another name for the bone bone. Tungging bone consists of four or five vertebral vertebrae that merge into one (Pearce, 2006). The function of the vertebral column or spinal cord is to work as a supporter of a sturdy body while also working as a buffer by intervertebral disk cartilage where the arch provides flexibility and allows bending without breaking. The discs are also useful for absorbing shocks that occur when moving heavy like when running and jumping, and thus the brain and spinal cord are protected against shocks. The hip ring is the link between the body and lower limbs. Part of the axial skeleton, or sacrum bone and coccyxus bone, which is squeezed between two koxa bones, also forms this bone. The two koxa bones are jointed with one another at the symphysis pubis place (Pearce, 2006). Figure 2.1: Vertebrae (Source: Google) 2.2.2 Structure of Lumbar Vertebrae Lumbar vertebrae is a bone segment that forms the lumbar region that consists of the vertebral body, vertebral arc and seven processes. The vertebral corpus is the ventral part that gives strength to the vertebral column and bears weight that is bounded by each other by the intervertebral discs and is held together by the ventral and dorsal longitudinal ligaments. The vertebrae are dorsal vertebrae consisting of pendiculus vertebrae and lamina arcus vertebra which are bound to one another by various ligaments including interspinosus ligament, intertransversal ligament and flavum ligament. The vertebral arc will form the vertebral foramen in the vertebral column which will form the spinal canal which contains the spinal cord and spinal nerve roots. Seven processes that emerge from the vertebral arc are (Moore and Dalley, 2004): 1. Spinous process The spinous process protrudes from the site of union of the two lamina and overlaps the dorsal side of the vertebra spinous process below. 2. Two transversal processes Two transverse processes protrude dorsolaterally from the site of the union of the vertebral arc and lamina arcus vertebrae. 3. The four articular processes The superior articular process and the inferior articular process also originate at the site of the union of the vertebral arc and lamina arcus vertebra. Figure 2.2 Lumbar Vertebrae (Source: Google) Lumbar I-V vertebrae are bigger and more sturdy than other regional vertebrae. Increased weight gain in the inferior vertebral column causes the lumbar vertebra to have a large corpus, so that the lumbar vertebra has characteristics, among others: Table 2.1. Special characteristics of the lumbar vertebra (Moore and Agur, 2002) PART CHARACTERISTICS Large vertebral corpus, such as the kidney when viewed from the superior triangular Foramen vertebralis, larger than the thoracic and smaller than the cervical Transversal process Long & slender, there are accessory processes on the posterior surface of each posterior surface processus articular process The superior facet leads to the postero-medial (or medial), inferior facet to the antero-lateral (or lateral) spinous process Short & strong, thick, wide and cube-shaped 2.2.3 Intervertebral discs Joints of the vertebral corpus including the joint type secondary condral (symphysis) which is designed to bear the burden and strength. The jointed surfaces of adjacent vertebrae obtain contact through a disc and ligament. Each intervertebral disc consists of an annulus fibrosus that is formed from regularly concentrated fibrocartilago lamels and surrounds the nucleus pulposus (Moore and Agur, 2002). Discus is a joint bearing with a function to allow broad motion in the vertebra (Anshar and Sudaryanto, 2011). This disc is thickest in the cervical and lumbar regions, where many vertebral columna movements occur. This physical characteristic shows its function as a shock absorber when the load on the vertebral column suddenly increases and the flexibility or spring force allows the rigid vertebrae to move with each other (Snell, 2006). The intervertebral discs will be subjected to any changes in body posture. Pressure that arises in the intervertebral disc loading can be a mechanical pressure that begins with the shifting of the nucleus pulposus toward the posterior or posterolateral due to incorrect body position when doing a job, so that when doing a movement, especially lumbar flexion will cause the emphasis on discus. If this continues, it will cause an irritated disc and over time there can be intervertebral discs (Pramita and Pangkahila, 2015). Figure 2.3 Intervertebral Discus (Source: Google) Each disc consists of 2 components: 1. Nucleus Pulposus Is a gelatinous substance that is jelly-shaped and transparent, containing 90% water, the rest is colagen and proteoglican which are special elements that are binding or attract water. Nucleus pulposus is a very strong hydrophilic and is chemically compiled by the mucopolysaccharida matrix containing protein bonds, chondroitin sulfate, hyaluronic acid and keratin sulfate. Nucleus pulposus has a very high fluid content so that it can withstand the compression load and serves to transmit several forces to the annulus and as a shock absorber (Anshar and Sudaryanto, 2011). 2. Annulus Fibrosus Composed by 90 concentric fibers of the collagen tissue that appear to be oblique crossing each other and becoming more oblique towards the central. Because the fibers are vertically crossing about 300 with each other causing this structure to be more sensitive to rotational strains than compression, tension and shear loads. The fibers are very important in the mechanical function of the intervertebral discs, the composition of the strong fibers protects the nucleus in them and prevents the prolapse of the nucleus. Mechanically the annulus fibrosus acts as a coiled spring to maintain the vertebral body when resisting resistance from the nucleus pulposus that works like a ball (Anshar and Sudaryanto, 2011). Figure 2.4 Annulus fibrosus and Nucleus Pulposus (Source: Google) 2.2.4 Facet Joint Facet joints are included in the non-axial diarthrodial joint. The facet joint is formed by the superior articular process of the lower vertebra with the inferior articular process of the upper vertebra. The mechanical function of the facet joint is to direct movement. The amount of motion in each vertebra is largely determined by the direction of the surface of the articular facet. The direction of the facet in the lumbar in the sagittal plane, thus permitting the breadth of dominant lumbar motion in the direction of flexion-extension (Anshar and Sudaryanto, 2011). In the lumbar region except for the lumbosacral joint facet articular located closer to the sagittal plane, the upper facet faces laterally and slightly anteriorly. The upper facet has a slightly concave surface and the lower facet is convex. Facet shape is what causes lumbar rotation movements are very limited (Pramita and Pangkahila, 2015). The facet joint also supports about 30% of the compression load on the spine, especially when the spine is hyperextension. The greatest contact force occurs in the L5-S1 facet joint (Anshar and Sudaryanto, 2011). If the intervertebral discs are in normal condition, the facet joint will support axial loads of about 3% to 25%, but this can increase to 70% if the intervertebral discs degenerate (Tischer, et al. 2006). Figure 2.5 Facet Joint (Source: Google) 2.2.5 Ligaments Stability in vertebrae is of two kinds namely passive stabilization and active stabilization. For passive stabilization is a ligament consisting of: 1. anterior longitudinal ligament anterior longitudinal ligament is a band of connective tissue that is strong and covers and connects the ventral parts of the vertebral corpus and the intervertebral disc. This ligament extends from the sacrum to the anterior tubercle C1 and the occipital os. Its function is to establish the position of the joints between the vertebral bodies and help prevent hyperextension of the vertebral column (Moore and Agur, 2002). 2. Posterior longitudinal ligament Posterior longitudinal ligament is a band of connective tissue that is somewhat weaker than the anterior longitudinal ligament. This ligament is in the vertebral canal along the posterior part of the vertebral body, extending from C2 to the sacrum. Its function is to help prevent vertebral colic hyperflection and protrusion of the dorsal intervertebral disc (Moore and Agur, 2002). In addition to the two main ligaments above, the vertebral column is still strengthened by the accessory ligament, namely: 1) Ligamentous flavum extending vertically from the lamina above to the lamina below it. This ligament helps maintain normal arches in the vertebral column and straightens the vertebral column after bending (Moore and Agur, 2002). These ligaments contain more elastin fibers than colagen fibers compared to other ligaments in the vertebrae (Anshar and Sudaryanto, 2011). . 2) Interspinosus ligament This ligament is very strong which is attached to the spinous process and extends posteriorly with the supraspinosus ligament (Moore and Agur, 2002). 3) Supraspinosus ligament This ligament is attached to each end of the spinous process. In the lumbar region the ligament is less clear because it integrates with the lumbosacral muscle insertion fibers. Together with the posterior ligament, the flavum ligament and the interspinosal ligament work as passive stabilizers in flexion movements (Anshar and Sudaryanto, 2011). 4) Intertransversal Ligament This ligament connects the transverse process and acts as a passive stabilizer on lateral flexion movement (Anshar and Sudaryanto, 2011) Figure 2.6 Vertebral Columna Ligaments (Source: Google) 2.2.6 Lumbar Vetebral Muscles two types, namely passive stabilization and active stabilization. For passive stabilization are ligaments, while those that function for active stabilization are muscles that function for lumbar locomotion. The muscles are as follows (Christophy, et al. 2012): 1. Intrinsic muscles The muscles in the lower back region are mostly included in the intrinsic group. Intrinsic muscles play a major role in vertebral columna movement and posture maintenance. But in the lower back region there are only intermediate and deep layers: 1) Intermediate layer Erector spine is intrinsic muscle in the intermediate layer. This muscle is divided into longissimus musculus, iliocostalis musculus and spinal musculus. This muscle group, called the long muscle, is the prime mover in lumbar extension movements and as a stabilizer of the lumbar vertebra when the body is upright. 2) deep layer The deep layer is composed of muscles that run obliquely, consisting of semispinal muscles, multifidus muscles and rotator muscles. These muscles originate from the lower vertebrae transverse process and attach to the vertebral spinous processes above. The work of these muscles is relatively inactive in a relaxed standing position, but its action is indispensable as a static postural muscle to maintain the stability of the vertebral column (Moore and Dalley, 2004). Figure 2.7 Paravertebral muscles (Source: Google) 2. Abdominal Abdominal muscles are extrinsic muscles that form and strengthen the abdominal wall composed of three layers. The first layer is the external oblique abdominis muscle, the second layer is the internal oblique muscle while the third layer is the transverse abdominis muscle and rectus abdominis muscle. 1) External oblique muscle berorigo on the external surface of the 5th to 12th ribs, insertion of the alba line, the pubic tubercle and the anterior portion of the iliac crista, functions for trunk flexion and rotation. 2) Internal oblique muscle berorigo of the thoracolumbar fascia, 2/3 of the anterior ciliary cysta and the lateral half of the inguinal ligament, insertion of the posterior side of the costa to 10-12, line alba and pekten pubis, function in compression and abdominal viscera support as well as flexion and rotation of the trunk in the 10th to 12th posterior ribs, the alba lineage and the pubic pubis, its function in compression and support of the abdominal viscera and the flexion and rotation of the trunk of the 10th to 12th rib . 3) Transversus abdominis muscle berorigo from the internal surface of the 7th-12th costa cartilage, thoracolumbar fascia, iliac crista and 1/3 lateral inguinal ligament, insertion in the alba linea, pubic crest, anterior layer of the rectus sheath and pubic pekten, function to attract and tighten the walls of the inguinal ligament, insertion of the alba linea, pubic crest, anterior layer of the rectus sheath and pubic pecten, function to attract and tighten the walls of the inguinal ligament, insertion in the alba linea, pubic crest, anterior layer of the rectus sheath and pubic pecten, abdominal, compression / pressing and supporting abdominal viscera. 4) Rectus abdominis muscle berorigo on pubic symphysis and pubic cristae, insertion in the xiphoid process and 5th to 5th rib cartilage, functions for trunk flexion, suppress abdominal viscera and control pelvic tilting (antilordosis). Figure 2.8 Abdominal muscles (Source: Google) 3. Deep lateral muscle Quadratus lumborum and psoas muscles can be inserted into the deep muscle layer of the lateral wall (Kapandji, 2010). This muscle group plays a role in lateral flexion and lumbar rotation. Figure 2.9 Deep lateral muscles (Source: Google) 2.2.7 Biomechanics of Lumbar Vetebra Biomechanics is the study of biological systems from a mechanical view. Judging from the breadth of joint motion, these joints include amphiartrosis (hyaline joint). The fields of motion include sagittal, transverse and frontal motion fields (Ansar and Sudaryanto, 2011). The motion of the vertebral column varies according to the area of the vertebral column and the nature of the individual. Freedom of movement of the vertebral column is mainly produced by the placement and flexibility of the intervertebral discs. In the lumbosacral vertebrae the movements that occur are flexion, extension, rotation, and lateral flexion (Kapandji, 2010): 1. Lumbar flexion movement Flexion is forward movement. This movement occupies the sagittal plane with the axis of frontal movement and can be done freely in the cervical and lumbar regions. When the lumbar moves the flexion of the intervertebral disc is compressed anteriorly and bulging posteriorly. At the same time the inferior articular process of the upper vertebra will shift toward the superior and away from the superior articular process of the lower vertebra. So that the ligaments that are between the articular processes will experience stretching. The normal angle of lumbar flexion movement is around 600. 2. Lumbar extension movement Extension is a backward movement. This movement occupies the sagittal plane with a frontal axis of movement and can be done freely in the cervical and lumbar regions. When the lumbar moves, the intervertebral disc extension is compressed posteriorly and bulging anteriorly. At the same time the articular processes of the lower and upper vertebrae become locked together, and the spinous processes can touch each other. The lumbar extension angle is around 350. 3. Rotational movement Rotation is the rotating motion of the vertebral column. This movement occurs in the horizontal plane with the axis through the spinous process with a normal angle formed 450 with the main driving muscle m. iliocostalis lumborum for lateral and counter lateral ipsi rotation, when the muscle contracts the rotation to the opposite side by m. obliqus externus abdominis. This movement is restricted by opposite side rotation muscles and interspinosus ligaments. 4. Lateral flexion Lateral flexion is the curved movement of the body to one side. When the lumbar moves laterally the flexion of the intervertebral disc will be compressed on the lateral side of the flexion. The contralateral intertranversus ligament will stretch while the ipsilateral side ligament relaxes. When viewed from the back, the articular processes move relative to each other so that the ipsilateral articular processes of the upper vertebra will move up and the contralateral side will move down. This movement occurs in the frontal plane and normal angles formed around 300. Figure 2.10 Vertebral Columna Movement (Source: Google) 2.2.8 Scope of Lumbar Joints In the spine between one bone and the other bones are separated by intervertebral discs where on this disc composed of annulus fibrosus and pulposus nucleus. The width of the dorsal joint (LGS) is determined partly by the distortion force of the disc resistance and partly by the angle and size of the articular surface between the processes. Largest back LGS occurs when the thickest disc conditions and the widest joint surface (Hislop and Montgomery, 2013). Conditions like the one above occur in the lower lumbar region precisely in the L-4, L-5 and S-1 areas so that a wider movement occurs at L-5 and S-1 than L-1 and L-2. Given the extent of the movement produced by L-5 and S-1 then the possibility of the joint injury or herniation or ostheoarthritis is greater than other joints. The movements that occur in the lumbar spine are flexion, extension, lateral flexion and rotation. Since there are no ribs that hold the lumbar region in motion, flexion and extension of the region are more likely than flexion-extension movements in the upper back. For the same reason the possibility of moving rotations is also relatively greater (Hislop and Montgomery, 2013). 1. Flexion Flexion in the lumbar region relaxes the anterior longitudinal ligament and extends the supraspinal ligament, interspinal ligament, posterior longitudinal ligament ligament. Flexion is limited by the size of our spine. To find out the area of motion that occurs in this joint, tell the patient to bend his back forward with a note that the knee must be straight and try to touch the tip of the toe. If the patient cannot do it, measure the distance between the tips of his fingers and the floor. Flexion in the lower back will not cause kyposis as happens in the neck region. Patients who have spasms in the paraspinal muscles will refuse to do this movement (Hislop and Montgomery, 2013). 2. Extension Extension in the lumbar region results in stretching of the anterior longitudinal ligament and relaxation of the posterior ligament. The back muscles are responsible for this movement and an increase in lumbar lordosis is retained by the abdominal rectus muscle. To test this extension by standing next to the patient and placing your hand on the posterior superior iliac spine and your fingers aligned with the patient’s midline line and have the patient move his or her back up as far as he can and give a little help gently by adding the scope of movement of the joint with pressure. Measure the movement and note it. (Hislop and Montgomery, 2013). 3. Lateral flexion Lateral flexion in the lumbar region is not pure movement, because there are many components that support this movement, especially components that give rise to rotational movements. To test this movement stabilize the patient’s iliaca crest and have the patient bend his back to the right and left as far as he can. Note how far the movement occurs and compare it with the other movement (Hislop and Montgomery, 2013). 4. Rotation To test this rotation stand next to the patient and stabilize the pelvis by placing one hand on the iliaca crest and the other hand on the shoulder of the surgery. Make a circular motion on the trunk and do the same procedure on the opposite side (Hislop and Montgomery, 2013). 2.3 Lumbar exercise Flexibility Procedure 1. Exercise 01 Position of the patient and procedure: Prone. Stabilize the patient (manually or with a belt) on the iliac crest on the concave side. Ask the patient to reach toward the knee with the arm on the side of the convex curve stretching the arm on the opposite side to the top of the head (Figure 2.11). Instruct the patient to inhale and develop the thoracic cage on the side being stretched. Figure 2.11 Exercise 01 (Source: personal documentation) 2. Exercise 02 Patient’s position and procedure: Prone. Ask the patient to stabilize the upper trunk (thoracic curve) by holding it on the end of the therapy table mat using his arm. Lift the hips and legs and position the trunk lateral to flexion away from the direction of the basin (Figure 2.12). Figure 2.12 Exercise 02 (Source: personal documentation) 3. Exercise 03 Position the patient and procedure: Sit on the heel (heel-sitting). Ask the patient to lean forward so that the abdomen is above the anterior thigh (Figure 2.13 A); bilateral arms stretched overhead, and hands flat on the floor. Then ask the patient to bend the trunk laterally away from the hollow by sliding the hand to the side of the convex curve. Hold that position to get a continuous stretch (Figure 2.13 B). Figure 2.13 A and B Exercise 03 (Source: personal documentation) 4. Exercise 04 Position of the patient and procedure: Lie on your side on a convex curve. Place a towel roll at the top of the curve, and ask the patient to stretch his upper arm over his head. Stabilization of the patient in the iliac crest. Do not let the patient roll forward or back during the stretch. Hold this position for continuous stretching (Figure 2.14). Figure 2.14 Exercise 04 (Source: personal documentation) 5. Exercise 05 Patient’s position and procedure: Lie on your side at the end of the therapy table with a towel roll at the top of the curve and your upper arm stretched overhead. Stabilization of the iliac crest. Hold the head down position as long as possible (Figure 2.15). Figure 2.15 Exercise 05 (Source: personal documentation) 6. Exercise 06 Positional Traction: Lumbar Excess positional traction is the main tractive force that can be directed to the side where the symptoms occur, or can be isolated to certain facets, so it is useful for selective stretching. Patient’s position: Lie on your side, with the side to be stretched on top. Thick blankets or towels are placed under the spine at a level that requires traction force; causes lateral flexion away from the side to be treated and, therefore, launches the facet upwards (Figure 2.16 A). Position of the therapist: Stand on the side of the therapy table facing the patient. Determine the segment that will receive the greatest traction force and palpate the spinous process at that level and above. Procedure: The patient relaxes in a lateral flexion position. Rotation is added to isolate the distraction force at the desired level. Rotate the upper trunk by lightly pulling the arm on the side where the patient lies while simultaneously palpating the spinous process with the hand. Figure 2.16 A and B Exercise 06 (Source: personal documentation) Your other to determine if the rotation has occurred exactly at the level above the joint to be distracted. Then, flex the patient’s upper thighs, palpate the spinous process again until there is flexion in the lower part of the spine at the desired level. The segment where these two opposing forces meet now has a maximum positional distraction force (Figure 2.16 B).