Download Module 2-- Lumbar Spine

GOALS OF LECTURE
Review clinically relevant anatomy of the lumbar spine
Learn assessment skills for somatic dysfunction of the lumbar spine
Learn the following manipulative techniques for the lumbar spine:
à soft tissue
à muscle energy
à counterstrain
à myofascial release
ANATOMY
“Because of its functional anatomic connections,
[the lumbar spine] can influence the head and
neck, the upper extremities, and even the
viscera.” Foundations, Chapter 40, pg 547.
5 total lumbar vertebrae, all of which are larger than the cervical & thoracic vertebrae
à The 5th lumbar vertebrae is the largest
The lumbar vertebrae have large, kidney shaped bodies, built to sustain the heavy,
functional, longitudinal loads that act on them
LUMBAR VERTEBRAE
Note the long, thin transverse processes.
à The transverse process location permits accurate range of motion testing of
the vertebra
The transverse processes are located in the same horizontal plane as its associated
spinous process.
The joint space of an intervertebral synovial joint is formed by the facet of an inferior
articular process of one vertebra and the facet of a superior articular process of
the next vertebra, (see the facets highlighted in green below)
The backward and medial orientation of the lumbar facets allow for the movement of
extension and flexion of the lumbar spine
A VERTEBRAL UNIT
A vertebral unit is made up of two vertebral segments and their associated
intervertebral disc, attached ligaments, and neurovascular elements.
When referring to somatic dysfunction of a lumbar segment, it is traditional to refer to
the vertebra most superior in the 2 vertebra unit
For example: when describing the motion of L4, we are speaking of the movement of
L4 on L5.
L4
L5
FRYETTE’S LAWS
In 1918, Harrison Fryette noticed that there were certain patterns and rules to lumbar
(and thoracic) spinal motion.
Law I – With the spine maintained in the neutral position (no flexion or extension),
if sidebending is introduced in one direction, rotation would occur in the opposite
direction
- applies to more than two vertebral segments
Law II – If the spine is moved into a non-neutral position of either flexion or extension,
when sidebending is introduced, rotation would occur in the same direction
- applies to a single vertebral segment
Example: If a patient is seated
and L4 is rotated left while the
lumbar spine is in extension, the
same L4 segment would also
sidebend left
L4
L5
MUSCLES
Erector spinae group or “paraspinals”
à spinalis
à longissimus
à iliocostalis
Lumbar multifidi and rotatores – deeper muscles
MUSCLES
Quadratus lumborum
Iliopsoas
LUMBAR SPINE
The spinous processes aid in counting the lumbar vertebrae
The L5 spinous process is small and lies in a hollow just above the sacral base, which
helps identify it as the last lumbar
Another way to count is to draw a line from the most superior portion of the iliac
crests and follow a horizontal plane midline which should lead you to the spinous
process of L4 and counting can then begin there.
L4
DIAGNOSIS OF SOMATIC DYSFUNCTION
Midline neutral
T. – Tissue Texture Changes
A. – Asymmetry
R. – Restricted Range of Motion
T. – Tenderness
à
L
Anatomic
barrier
L
Physiologic
barrier
Restrictive barrier
At least 2 of the above criteria must be present for diagnosis of somatic dysfunction;
however, the more of these components that are present, the stronger association
with somatic dysfunction.
LUMBAR VERTEBRAL MOTIONS
Flexion (forward bending) & Extension (backward bending)
à The lumbar spine has ~40-60°of flexion and ~20-35°of extension
Sidebending (lateral flexion)
à Sidebending of the vertebra is named by the concavity of the spine
à Normal range of motion for lateral bending is 15-20°
concave left
Rotation
à Rotation of a vertebra is named by motion of the point on the anterior/superior
surface of a vertebra
à Normal range of motion for rotation is 3-18°
Anterior view of
lumbar spine
SIDEBENDING
In this photo, the lumbar vertebra is sidebent left. Lateral translation of a vertebra to one side induces
sidebending towards the other side
à Freedom of motion with right lateral translation forces on the LEFT transverse process
à Restriction of motion with left lateral translation forces on the RIGHT transverse process
The L3 vertebra is translated laterally to the RIGHT more freely, which induces LEFT sidebending.
Diagnosis: L3 Sidebent Left
ROTATION
In this photo, the anterior/superior surface of the lumbar vertebra is rotated right.
à Freedom of motion with anteriorly-directed forces on the LEFT transverse process
à Restriction of motion with anteriorly-directed forces on the RIGHT transverse process
Diagnosis: Lumbar vertebra Rotated Right
DIAGNOSIS
1.) Identify the lumbar segment that meets TART criteria
à Ex: L1 vertebrae is +tenderness, +asymmetry
2.) Assess the lumbar segment’s range of motion
Rotation – is the anterior/superior aspect of the lumbar vertebrae rotating more
easily to the right or the left?
Sidebending – move the transverse process of a lumbar vertebrae laterally in one
direction to induce sidebending in the opposite direction. Which motion is easier?
Flexion/Extension – does the segment freely move anteriorly suggesting
extension or does is resist anterior motion suggesting flexion?
3.) Vertebral segment somatic dysfunction is diagnosed and named according to how
the segment LIKES TO MOVE.
à L1 Extended, rotated right, sidebent right = L1 ERRSR
ASSESSMENT SKILLS
http://www.acofp.org/acofpimis/acofporg/apps/OMT/index.html
•  Watch video titled: “Examination of the Lumbar Spine”
Most beginners prefer the prone position for examination of the lumbar spine.
Prone position is ideal for evaluating tenderness and tissue texture abnormality.
Seated position is ideal for motion testing because the table does not restrict
motion.
ACOFP OMT Video Library website:
http://www.acofp.org/ACOFPIMIS/Acofporg/Education_Online_Learning/OMT_Resources/
Acofporg/Education_Online_Learning/OMT_Resources.aspx?hkey=81b3c4e5-7db7-4877b663-1e13602c3cf7
Access key: 152130
CASE #1
S: A 37 y/o M presents to your office with lower back pain, which started about 5 days
ago. The pain has been a progressively worsening constant ache, felt more on his
left side than right. He feels that it is worse at night, specifically when he lies
prone on his bed. It is also hard for him to stand up straight after he’s been sitting
for long periods of time. Last week he had multiple car trips >5 hours a day for
various work events.
O: He is leaning forward towards the left when he enters the exam room. Afebrile.
RRR. CTAB. DTR 2+ bilaterally, normal motor and sensory function.
Osteopathic Exam: where do you start?
List screening structural exam components
à See next slide for examination of the lumbar spine
LUMBAR SPINE DIAGNOSIS
1.) Identify the lumbar segment that meets TART criteria
à Ex: L1 vertebrae is +tenderness, +asymmetry
2.) Assess the lumbar segment’s range of motion
Rotation – is the anterior/superior aspect of the lumbar vertebrae rotating more
easily to the right or the left?
Sidebending – move the transverse process of a lumbar vertebrae laterally in one
direction to induce sidebending in the opposite direction. Which motion is easier?
Flexion/Extension – does the segment freely move anteriorly suggesting
extension or does is resist anterior motion suggesting flexion?
3.) Vertebral segment somatic dysfunction is diagnosed and named according to how
the segment LIKES TO MOVE.
à L1 Flexed, rotated left, sidebent left = L1 FRLSL
PSOAS MUSCLE ANATOMY
Action of the psoas:
- Flexion of the hip
joint
- External rotation
- Sidebends the
lumbar vertebral
column
Origin of psoas muscle:
-  T12 anterior surface of
the vertebral body
-  L1/L2 anterior surface of
the vertebral body AND
inferior border of the
transverse process
-  L3/4 anterior surface of
the vertebral body AND
inferior border of the
transverse process
-  L5 inferior border of the
transverse process
This is how the
psoas muscle
influences
lumbar
dysfunction.
PSOAS DIAGNOSIS
Psoas dysfunction is characterized by a hypertonic, short psoas major muscle, which
resists lengthening.
Testing for psoas dysfunction is an integral part of lumbar evaluation.
A tight psoas restricts hip extension in the prone position.
Additionally, psoas dysfunction is accompanied by a flexed upper lumbar, rotated and
sidebent to the side of the shorter psoas.
Look for the flexed upper lumbar component in any psoas problem.
MUSCLE ENERGY
A manipulative technique in which the patient uses their muscles, on request, from a
precisely controlled position, in a specific direction, against an operator
counterforce.
General Treatment Principals of Muscle Energy
à Take the restricted muscle to a barrier opposite of the diagnostic finding
à Let the muscle group perform its motion with gentle effort (~3lbs of force) with
the patient resisting against the barrier using an isometric force for 3 seconds
à Rest/relax the muscle group for 3 seconds
à Repeat by bringing to a new barrier.
à Perform this sequence 3 times.
PSOAS TREATMENT
http://www.acofp.org/acofpimis/acofporg/apps/OMT/index.html
•  Watch “Psoas Stretch, Patient Prone”
•  Watch “Psoas (Muscle Energy)”
LUMBAR MUSCLE ENERGY TREATMENT
http://www.acofp.org/acofpimis/acofporg/apps/OMT/index.html
•  Watch “Lumbar Walk-Around”
In the Muscle Energy portion, positioning is the same, but instead of final thrust force,
engage the barrier then have patient rotate against your force.
CASE #1
S: A 37 y/o M presents to your office with lower back pain, which started about 5 days
ago. The pain has been a progressively worsening constant ache, felt more on his
left side than right. He feels that it is worse at night, specifically when he lies
prone on his bed. It is also hard for him to stand up straight after he’s been sitting
for long periods of time. Last week he had multiple car trips >5 hours a day for
various work events.
O: He is leaning forward towards the left when he enters the exam room. Afebrile.
RRR. CTAB. DTR 2+ bilaterally, normal motor and sensory function.
Osteopathic Exam:
Lumbar spine- L1FRLSL.
Lower extremity- Hypertonic Psoas (extension of the left thigh is restricted
in the prone position).
A: Low back pain, Somatic Dysfunction of lumbar spine and lower extremity
P: Muscle energy to left psoas, improved somatic dysfunction. Muscle energy to L1,
improved somatic dysfunction. Patient symptoms improved.
CASE #2
S: A 78 y/o F who is temporarily wheelchair bound due to a fall on ice presents to your
office for right low back pain. This pain started 1 weeks ago, and her daughter-inlaw decided to bring her in because she seemed to be in more pain recently. The
pain is a throbbing sensation with intermittent shooting pains down the back and
into her right thigh. She is also complains of exquisite pain on her R hip bone
whenever someone helps move her from the wheelchair.
O: She is wheelchair bound, but able to ambulate with assistance. You note that her
right foot is maintained in external rotation on the foot paddle.
Osteopathic Exam: where do you start?
SOFT TISSUE
Indication: hypertonic lumbar paraspinals
http://www.acofp.org/acofpimis/acofporg/apps/OMT/index.html
•  Watch “Soft Tissue, Range of Motion, Patient on Side”
CASE #2
S: A 78 y/o F who is temporarily wheelchair bound due to a fall on ice presents to your
office for right low back pain. This pain started 1 weeks ago, and her daughter-inlaw decided to bring her in because she seemed to be in more pain recently. The
pain is a throbbing sensation with intermittent shooting pains down the back and
into her right thigh. She is also complains of exquisite pain on her R hip bone
whenever someone helps move her from the wheelchair.
O: She is wheelchair bound, but able to ambulate with assistance. You note that her
right foot is maintained in external rotation on the foot paddle.
Osteopathic Exam:
Lumbar - hypertonic paraspinals, anything else?
TENDER POINTS
Tender points
à small tense edematous areas of tenderness
à about the size of a fingertip
à located near bony attachments of tendons/ligaments or in the belly of a
muscle
Counterstrain is a passive indirect technique in which the somatic dysfunction being
treated is positioned at a point of balance, or ease, away from the restrictive
barrier.
- treats tender points
ANTERIOR LUMBAR TENDER POINTS
L1: just medial to the ASIS
L2-L4: on the AIIS
L5: 1 cm lateral to the pubic symphysis on the superior ramus
COUNTERSTRAIN TECHNIQUE OVERVIEW
1.  Find a significant tender point
2.  Establish a pain scale, 10/10
3.  Monitor the tender point as you position the patient in the standard treatment
position
4.  Recheck tender point. Goal reduction of tenderness to 0, however reduction to
30% of original pain is considered acceptable
5.  Fine-tune the position as needed
6.  Monitor the tender point and hold treatment position for 90 seconds
7.  SLOWLY return the patient to neutral without his/her assistance
8.  Recheck the tender point
ANTERIOR LUMBAR COUNTERSTRAIN
http://www.acofp.org/acofpimis/acofporg/apps/OMT/index.html
•  Watch “Anterior Lumbar Tender Points: Counterstrain”
CASE #2
S: A 78 y/o F who is temporarily wheelchair bound due to a fall on ice presents to your
office for right low back pain. This pain started 1 weeks ago, and her daughter-inlaw decided to bring her in because she seemed to be in more pain recently. The
pain is a throbbing sensation with intermittent shooting pains down the back and
into her right thigh. She is also complains of exquisite pain on her R hip bone
whenever someone helps move her from the wheelchair.
O: She is wheelchair bound, but able to ambulate with assistance. You note that her
right foot is maintained in external rotation on the foot paddle.
Osteopathic Exam:
Lumbar - hypertonic paraspinals, right AL1 tender point, anything else?
PIRIFORMIS MUSCLE ANATOMY
Action of the piriformis:
- External rotation
- Abduction and extension of
the hip joint
- Stabilization of the hip
Piriformis tender point
- in the piriformis muscle
~7cm medial to and slightly
cephalad to the greater trochanter
Origin of piriformis muscle:
- Pelvic surface of the sacrum
Insertion of the piriformis muscle:
-Superior border of the
trochanter of the femur
PIRIFORMIS TREATMENT
http://www.acofp.org/acofpimis/acofporg/apps/OMT/index.html
•  Watch “Piriformis Muscle Tender Point”
CASE #2
S: A 78 y/o F who is temporarily wheelchair bound due to a fall on ice presents to your
office for right low back pain. This pain started 1 weeks ago, and her daughter-in-law
decided to bring her in because she seemed to be in more pain recently. The pain is a
throbbing sensation with intermittent shooting pains down the back and into her right
thigh. She is also complains of exquisite pain on her R hip bone whenever someone
helps move her from the wheelchair.
O: She is wheelchair bound, but able to ambulate with assistance. You note that her right
foot is maintained in external rotation on the foot paddle.
Osteopathic Exam:
Lumbar – hypertonic paraspinals, right AL1 tender point
Lower extremity – right piriformis tender point
A: Low back pain, Somatic Dysfunction of lumbar spine and lower extremity
P: Soft tissue to lumbar paraspinals, improved somatic dysfunction. Counterstrain to AL1
and piriformis, improved somatic dysfunction. Patient symptoms improved.
CASE #3
S: A 14 y/o F who presents to your clinic with three months of low back pain. She is
an avid volleyball player and has been noticing worsening symptoms while
playing. The pain is located more on her right lower back but she also has pain in
her midline midline sacrum area. She is right handed and notices the pain more
with serving. She has tried rest, as much as possible, heat and ice with minimal
improvement.
O: She moves comfortably around the room. Able to transfer to the table without pain
or distress. No gait abnormalities. DT 2+ bilaterally, normal muscle strength and
sensation
Osteopathic Exam: what would be your approach?
CASE #3
S: A 14 y/o F who presents to your clinic with three months of low back pain. She is
an avid volleyball player and has been noticing worsening symptoms while
playing. The pain is located more on her right lower back but she also has pain in
her midline midline sacrum area. She is right handed and notices the pain more
with serving. She has tried rest, as much as possible, heat and ice with minimal
improvement.
O: She moves comfortably around the room. Able to transfer to the table without pain
or distress. No gait abnormalities. DT 2+ bilaterally, normal muscle strength and
sensation
Osteopathic Exam:
- Screening structural exam
à you note decreased left lumbar sidebending and pain with trunk extension
- Examination of the lumbar spine
à you find tissue texture change and restriction of motion at the L5 level
and a tenderpoint of the quadratus lumborum at the superior iliac crest
attachment
L5 ON S1
It is common to see Fryette’s type II dysfunction at L5 on S1
L5
TP
L5 SP
L5
S1
L5
SP
L5 TP
MYOFASCIAL RELEASE
Useful for any kind of myofascial restriction
Can be applied direct, indirect, or combined (eg, indirect followed by direct)
Engages barrier with continuous palpatory feedback
Activating forces augment the treatment process
Same principles can be applied to ligamentous or arthroidal restrictions as well
L5 MYOFASCIAL TREATMENT
https://youtu.be/Fr063HhojBU
•  Watch “MFR L5S1”
QUADRATUS LUMBORUM ANATOMY
Origin: poster part of the iliac crest and the
iliolumbar ligament
Insertion: 12th rib and the transverse process
of the lumbar vertebrae L1-L5
Action: Bends the trunk ipsilaterally,
fixes the 12th rib, aids in exhalation
QUADRATUS LUMBORUM TENDER POINTS
Three possible locations:
à inferior to the 12th rib, just lateral of
the lumbar paraspinal muscles
à on the lateral aspects of the L1-L5
transverse processess (only L2/L3
depicted here)
à superior aspect of the iliac crest
QUADRATUS LUMBORUM TREATMENT
https://youtu.be/UJ075bOa61M
•  Watch “QL CS”
CASE #3
S: A 14 y/o F who presents to your clinic with three months of low back pain. She is an avid
volleyball player and has been noticing worsening symptoms while playing. The pain is
located more on her right lower back but she also has pain in her midline midline
sacrum area. She is right handed and notices the pain more with serving. She has
tried rest, as much as possible, heat and ice with minimal improvement.
O: She moves comfortably around the room. Able to transfer to the table without pain or
distress. No gait abnormalities. DT 2+ bilaterally, normal muscle strength and
sensation
Osteopathic Exam:
Lumbar – L5FRRSR, Quadratus lumborum tender point
A: Low back pain, Somatic Dysfunction of lumbar spine
P: Myofascial release of L5 (direct or indirect), improved somatic dysfunction. Counterstrain
of quadratus lumborum tender point, improved somatic dysfunction. Patient symptoms
improved.
TECHNIQUES SUMMARY
Soft Tissue:
•  Lumbar paraspinal muscles
Muscle energy:
§  Psoas muscle
§  L1-L4 , seated muscle energy
Counterstrain:
§  Anterior lumbar tender point
§  Piriformis muscle tender point
§  Quadratus lumborum muscle tender point
Myofascial Release
•  L5 on S1
REFERENCES
American College of Osteopathic Family Physicians. OMT Procedures. 2015. Web. 28
Sept. 2016.
Chila, Anthony. Foundations of Osteopathic Medicine 3rd Edition. LWW, 2010. Print.
Nelson, Kenneth, and Thomas Glonek. Somatic Dysfunction in Osteopathic Family
Medicine, 2nd edition. LWW, 2014. Print.
Rowane, Michael, and Paul Evans. Basic Musculoskeletal Manipulation Skills: The 15Minute Office Encounter. American Academy of Osteopathy, 2012. Print.
Savarese, Robert G. OMT Review 3rd Edition. Legis Press, 2003. Print.
Snider, Karen, and John Glover. Atlas of Common Counterstrain Tenderpoints. ATSU Kirksville College of Osteopathic Medicine, 2014. Print.
3D4Medical.com, LLC. (2016). Essential Anatomy 5 (Version 5.0.2) [Mobile
application software]. Retrieved from http://itunes.apple.com.