Osteopathic Lumbar Treatment

by Sheldon C. Yao, DO

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    00:01 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.

    00:10 I’m going to use my palms here and make good contact, not on the spinous process.

    00:15 I’m going to be pushing on the muscles opposite from where I’m standing.

    00:19 I place my palms on the muscle. Make good contact. Sink in to the muscle a little bit.

    00:25 Then start to push away and hold that stretch until I feel a little bit of softening.

    00:31 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.

    00:39 What I’m going to do is I'm going to put one palm down and the other palm opposite.

    00:43 We could bring the tissue together and then slowly push it apart.

    00:47 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.

    01:01 This helps to give me a little bit more torque and stretch.

    01:05 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.

    01:15 Anterior Lumbar Counterstrain Points: The anterior counterstrain points are located close to the ASIS, the AIIS, and the pubic tubercle.

    01:27 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.

    01:40 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.

    01:50 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.

    02:10 Then AL5 will be located just on the pubic tubercle itself.

    02:16 What we want to do is to find a mobile point for these points.

    02:21 So, we found a tender point. All of these points are treating flexion with some variation of rotation and side bending.

    02:28 So for AL1, the positioning is flexion, rotation towards, and side bending towards.

    02:36 So, we’re going to bend the knees. Then we’re going to flex the patient’s pelvis and hips.

    02:45 We’re going to support the weight of their legs on our thigh here.

    02:52 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.

    03:12 Have dialogue with the patient to make sure that this position achieves zero pain.

    03:18 Then after holding it for 90 seconds, we’re going to slowly bring it back.

    03:22 Ask the patient not to help us. Then slowly bring the legs back and reassess for pain.

    03:27 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.

    03:54 Posterior Lumbar Counterstrain: The tender points for the lumbar spine could be found on the spinous process or on the transverse processes.

    04:05 If we want to treat a midline spinous process tender point, the mobile position could be accomplished by usually extending one leg.

    04:14 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.

    04:28 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.

    04:54 This would be the mobile point for a posterior transverse tender point.

    05:00 So again, you want to apply counterstrain and go through all the different steps.

    05:04 But that would be the location and positioning for lumbar spinous process and transverse process tender points.

    05:12 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.

    05:39 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.

    05:49 Then we’re going to reengage the barrier and push down again, one, two, three, relax.

    05:54 Then one last passive stretch and you bring the patient back down.

    05:58 You recheck for the type 1 curve and see if the group curve has improved.

    06:04 If we have a type II somatic dysfunction, it could be a flexion or extension dysfunction.

    06:09 So if I have a flexion dysfunction, what we’re going to do is remember the mnemonic, FDR.

    06:15 For a flexion dysfunction, we’re going to have the patient push their legs down.

    06:20 The patient is going to be in a lateral recumbent position.

    06:23 So, we start off by putting the dysfunction side up.

    06:26 The posteriorly rotated transverse process will be up.

    06:31 I’m going to contact that posterior transverse process. Let’s say this is L2.

    06:36 Since it’s on the left side, this will be L2 FRS left.

    06:42 We’re going to flex the knees up until we feel motion at that segment.

    06:46 Then we’re going to have them straighten out their bottom leg and extend that leg.

    06:53 We’re going to hook this underneath in the popliteal fossa.

    06:57 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.

    07:05 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.

    07:13 Remember, we’re going to have the ankles push down.

    07:18 So, we’re going to bring the ankle up and that side bends them into the barrier.

    07:22 Go ahead gently push down to the floor, one, two, three, relax.

    07:26 We reengage the barrier and push down again, one, two , three, relax.

    07:30 Reengage the barrier one more time and push down, one, two, three, and relax.

    07:35 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.

    07:43 Then you can reassess that point. So, that was treatment for a type II flexion dysfunction.

    07:50 If we had a type II extension dysfunction, then the mnemonic would be SUE.

    07:55 S is for Sims, U is for up which is the direction which the patient will be pushing their ankles.

    08:02 E is for extension dysfunction. So here, let’s take the same example.

    08:06 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.

    08:18 So first, we’re going to flex until we feel motion at L2.

    08:21 This time I’m going to have the patient hug the table.

    08:24 So when they hug the table, you’re going to rotate them into the barrier.

    08:28 We’re going to have them push their ankles up for SUE.

    08:32 Go ahead and push your ankle up and relax.

    08:35 So here, we’re side bending into the barrier and having them push your ankles up again, one, two, three, relax.

    08:42 Then one last time, push up, one, two, three, relax, and then one passive stretch.

    08:47 Then you can have the patient relax and lie on their stomach.

    08:51 Then you can go ahead and reassess.

    08:54 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.

    09:02 HVLA for the Lumbar Spine: What we want to do here is to screen and check for a type II dysfunction.

    09:10 Here, we have an L2 FRS left. So we want to treat this with HVLA.

    09:15 First, we do some myofascial, free up the soft tissue.

    09:18 Then we’re going to have the patient lie on their side facing you.

    09:21 This way, the affected somatic dysfunction, the posterior transverse process is up.

    09:27 We’re going to flex the knees until we feel motion at L2.

    09:30 We’re going to have them straighten out the bottom leg.

    09:32 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.

    09:40 This holds the flexion in the lower part.

    09:43 You’re going to switch your monitoring hand.

    09:45 You’re going to have the patient grab onto your shoulder and lean their opposite shoulder back. So, you rotate them into the barrier.

    09:50 You’re going to get your hand underneath them and stabilize.

    09:54 Now, you’re going to switch your monitoring finger.

    09:58 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.

    10:06 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.

    10:15 Have the patient take a breath in and breathe out.

    10:17 As they breathe out, this is going to support and hold the rotation away.

    10:21 This is going to bring the leg down towards the floor.

    10:24 Breathe in again and breathe out. You lock the segment out.

    10:28 Breathe in again and breathe out. Then when they breathe all the way out, you could apply a quick thrust down to the table.

    10:35 Then you could have them lie on their stomach. Then you could reassess to see if the treatment was successful in correcting somatic dysfunction.

    About the Lecture

    The lecture Osteopathic Lumbar Treatment by Sheldon C. Yao, DO is from the course Osteopathic Treatment and Clinical Application by Region. It contains the following chapters:

    • Lumbar Myofascial Technique
    • Anterior Lumbar Counterstrain Points
    • Posterior Lumbar Counterstrain Points
    • Muscle Energy for Lumbar Spine
    • High-velocity, Low-amplitude for Lumbar Spine

    Author of lecture Osteopathic Lumbar Treatment

     Sheldon C. Yao, DO

    Sheldon C. Yao, DO

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