Lumbar Myofascial Technique: If we have
hypertonic muscle in the lumbar spine,
we could apply these techniques to try to
loosen and decrease the muscle spasm.
I’m going to use my palms here and make
good contact, not on the spinous process.
I’m going to be pushing on the muscles
opposite from where I’m standing.
I place my palms on the muscle. Make good contact.
Sink in to the muscle a little bit.
Then start to push away and hold that stretch
until I feel a little bit of softening.
So, this would be a perpendicular stretch.
We could also do a parallel stretch
with how the muscles run. We’re addressing the erector spinae muscles.
What I’m going to do is I'm going to put one
palm down and the other palm opposite.
We could bring the tissue together
and then slowly push it apart.
This would be a parallel stretch. We could also
augment the perpendicular stretch
in the lumbar spine by grabbing the ASIS and
lifting it up as we’re pushing out laterally.
This helps to give me a little bit
more torque and stretch.
Remember with myofascial stretches
to perform the stretch slowly
and to release the muscle slowly.
Then you can reassess afterward
to see how successful
the technique was.
Anterior Lumbar Counterstrain Points:
The anterior counterstrain points
are located close to the ASIS, the AIIS,
and the pubic tubercle.
We’re going to review the location of this and
show you how to set up for
the mobile points. The ASIS here just medial to it,
you’ll find anterior lumbar 1, so AL1.
If you come a little bit inferior about an inch
from the bottom of the ASIS,
you’ll find the AIIS, the anterior
inferior iliac spine.
So, if you have the patient push their knee up
towards the ceiling, go ahead and push,
that’s the attachment of the quadriceps.
So, you can kind of feel
where the tendon attaches to the AIIS.
Once you locate the AIIS,
the AL2 will be just medial to it, AL3 just
lateral to it, and AL4 just inferior to it.
Then AL5 will be located just
on the pubic tubercle itself.
What we want to do is to find a
mobile point for these points.
So, we found a tender point. All of
these points are treating flexion
with some variation of
rotation and side bending.
So for AL1, the positioning is flexion,
rotation towards, and side bending towards.
So, we’re going to bend the knees. Then we’re going to
flex the patient’s pelvis and hips.
We’re going to support the weight
of their legs on our thigh here.
For rotation, what we’re going to do is
we’re going to bring the knees towards,
to rotate towards me. Then with the ankles,
we’re going to bring the ankles towards me
to create side bending. So we’re going to flex,
rotate towards, and side bend towards
for AL1. Going through all the motions of counterstrain,
make sure we establish a pain scale.
Have dialogue with the patient to make sure
that this position achieves zero pain.
Then after holding it for 90 seconds,
we’re going to slowly bring it back.
Ask the patient not to help us. Then slowly
bring the legs back and reassess for pain.
So, based on the point that you’re
treating, it’s going to be flexion
and some variation of whether you’re
side bending towards or side bending away
by standing on the opposite side.
So, you can refer to the chart
on the anterior lumbar positioning to look at
the points and which side of the patient
you should stand on, and how you should
rotate and side bend the patient to achieve
the mobile point. So, that is treatment
for the anterior lumbar counterstrain points.
Posterior Lumbar Counterstrain: The tender
points for the lumbar spine could be found
on the spinous process or
on the transverse processes.
If we want to treat a midline
spinous process tender point,
the mobile position could be accomplished
by usually extending one leg.
Usually, if you can’t get the relief
of pain by lifting one leg,
you kind of throw your knee underneath
and then lift up the opposite leg too
to create more extension,
to try to reach the mobile point.
If the patient has a transverse process
tender point, what you’re going to do
is to stand on the opposite side
because treatment will be extension
and adduction of the ipsilateral leg.
So here, if we had a tender point
on the right side here, I’m going to get a good
purchase on the thigh above the knee
at extension until I feel motion and a little bit of adduction, external rotation.
This would be the mobile point for a
posterior transverse tender point.
So again, you want to apply counterstrain
and go through all the different steps.
But that would be the
location and positioning
for lumbar spinous process and
transverse process tender points.
Muscle Energy for the Lumbar Spine:
Depending in what we find in the lumbar spine,
we can utilize muscle energy to treat it.
So if we had a type 1 group curve,
we’re going to put the convexity side up.
We’re going to bend the knees
until we feel motion at the apex of the curve.
We’re going to bring the ankles up
towards the ceiling. It would cause
side bending into the barrier
and have them push the ankles
down towards the floor.
Go ahead and push, one, two, three,
relax. You can reengage the barrier
by side bending more and push down again,
one, two, three, relax, and relax.
Then we’re going to reengage the barrier and
push down again, one, two, three, relax.
Then one last passive stretch
and you bring the patient back down.
You recheck for the type 1 curve and
see if the group curve has improved.
If we have a type II somatic dysfunction,
it could be a flexion or extension dysfunction.
So if I have a flexion dysfunction, what we’re going
to do is remember the mnemonic, FDR.
For a flexion dysfunction, we’re going to have
the patient push their legs down.
The patient is going to be in
a lateral recumbent position.
So, we start off by putting
the dysfunction side up.
The posteriorly rotated
transverse process will be up.
I’m going to contact that posterior
transverse process. Let’s say this is L2.
Since it’s on the left side,
this will be L2 FRS left.
We’re going to flex the knees up
until we feel motion at that segment.
Then we’re going to have them straighten out
their bottom leg and extend that leg.
We’re going to hook this
underneath in the popliteal fossa.
I’m going to shift monitoring hands. I’m going to
have him grab onto my shoulder
and lean their shoulder, opposite
shoulder back as we rotate to L2.
You’re going to hold on to your elbows there.
Now, we’re going to come back,
switch monitoring hand again.
I’m going to grab the ankle.
Remember, we’re going to have
the ankles push down.
So, we’re going to bring the ankle up
and that side bends them into the barrier.
Go ahead gently push down to
the floor, one, two, three, relax.
We reengage the barrier and push
down again, one, two , three, relax.
Reengage the barrier one more time
and push down, one, two, three, and relax.
We do a little bit of a passive stretch,
side bending into the barrier,
and then bring the patient back.
Then have them lie back on their side.
Then you can reassess that point. So, that was
treatment for a type II flexion dysfunction.
If we had a type II extension dysfunction,
then the mnemonic would be SUE.
S is for Sims, U is for up which is the direction
which the patient will be pushing their ankles.
E is for extension dysfunction. So here,
let’s take the same example.
We have an L2 but this time
it’s going to be extended,
rotating in side bend left dysfunction.
So again, extension dysfunction,
you want to put the patient
into Sims position.
So first, we’re going to flex
until we feel motion at L2.
This time I’m going to have
the patient hug the table.
So when they hug the table, you’re going to
rotate them into the barrier.
We’re going to have them push
their ankles up for SUE.
Go ahead and push your
ankle up and relax.
So here, we’re side bending into the
barrier and having them push
your ankles up again,
one, two, three, relax.
Then one last time, push up, one, two, three,
relax, and then one passive stretch.
Then you can have the patient relax
and lie on their stomach.
Then you can go
ahead and reassess.
So, those are the three different
ways that we could apply
muscle energy to type I and type II somatic
dysfunctions in the lumbar spine.
HVLA for the Lumbar Spine:
What we want to do here
is to screen and check
for a type II dysfunction.
Here, we have an L2 FRS left.
So we want to treat this with HVLA.
First, we do some myofascial,
free up the soft tissue.
Then we’re going to have the patient
lie on their side facing you.
This way, the affected somatic dysfunction,
the posterior transverse process is up.
We’re going to flex the knees
until we feel motion at L2.
We’re going to have them
straighten out the bottom leg.
Then you’re going to extend and
make sure the leg is straightened
and then just hook the patient’s foot
behind their popliteal fossa.
This holds the flexion
in the lower part.
You’re going to switch
your monitoring hand.
You’re going to have the patient
grab onto your shoulder
and lean their opposite shoulder back.
So, you rotate them into the barrier.
You’re going to get your hand
underneath them and stabilize.
Now, you’re going to switch
your monitoring finger.
With your forearm here, you’re going to
rest this by the greater trochanter
by the thigh here. So, you’re going to
take the pelvis and rotate it.
As you rotate it quickly, it’s going to
create a force here to correct
that lumbar somatic dysfunction. So first,
you want to lock the segment out.
Have the patient take a
breath in and breathe out.
As they breathe out, this is going to
support and hold the rotation away.
This is going to bring the leg
down towards the floor.
Breathe in again and breathe out.
You lock the segment out.
Breathe in again and breathe out.
Then when they breathe all the way out,
you could apply a quick
thrust down to the table.
Then you could have them lie on their stomach.
Then you could reassess to see
if the treatment was successful
in correcting somatic dysfunction.