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Lecture 1: Lumbar: Indirect

Objectives:
a. List and describe the common indirect osteopathic techniques.
b. Give examples of indirect techniques and explain their activating forces.
c. Define and describe the appropriate application of indirect techniques to the lumbar spine.
d. Review the indications/contraindications for indirect treatment.
e. Discuss the barrier concept and how it applies to indirect osteopathic techniques.
f. Introduce and describe kinetic chain imbalance.
g. Describe muscle imbalance patterns in hip and pelvis, specifically “dead butt”, piriformis and psoas
syndrome, and their treatments
h. Demonstrate FPR techniques for Piriformis, Lumbar and Sacrum

 Low Back Pain: Incidence


 85 % of the general population will have low back pain (LBP)
 Most common reason to see a physician for musculoskeletal condition
 Second most common pain complaint
 35% of adolescent athletes
 27 % LBP in adults is MS strains
 Overuse injuries are prone to recurrence
 26% males/33% females
 Risk regardless of sex, age, occupation, etc.
 Medical Expenditure Panel Survey (MEPS)
 Costs inc 65% from 1997-2005 to $86 billion
 Avg cost of single work related back injury is over $8000
 Adults with functional limitations inc by 19%

Requirements
- In order to treat with indirect techniques (or direct for that matter) you must have a firm understanding of the
where the dysfunctional facet is located that is causing your somatic dysfunction and the findings c/w the
diagnosis.
- (review dysfunctional facets briefly)

Terminology
 Why is this important?
- Each school not only teaches things differently, they describe things differently.
- Board questions are written by all the faculty of the various schools
 Review: L3 N Sright Rleft:  Review: L3 ESRright:

 Review: L3 N Sleft Rright:  Review: L3 FSRleft:

 Review: L3 ESRleft:  Review: L3 FSRright:


 Facilitated Postional Release (FPR):
 Intro:
 Indirect positional method of treatment
 Developed by Stanley Schiowitz, D.O. in 1977
 Developed because he wanted a fast and effective treatment for patients due to his busy private practice.
 Components of FPR were used by prior physicians including A.T. Still.

 Neurophysiology:
 “immobility of a lesioned segment was initiated or maintained by an
increased gain in gamma motor neuron activity of that segment” - Korr.
 “an inappropriately high gain-set of the muscle spindle results in changes
characteristic of somatic dysfunction” - Bailey.
 The primary neurophysiologic mechanism affected by FPR is thought to
be the relationship between Iα-afferent and γ-efferent activity
 If the dysfunctional segment is positioned appropriately, the fibers may
return to normal length, which decreases tension in the fibers
 This reduced tension in the area of the muscle spindle eliminates the
afferent excitatory impulses
 This “quiets” the gamma motor gain, reducing the stretch stimuli, and eliminates the reflex activation of the
α-motor neuron
 This allows the tension and hypertonicity of the muscles to “reset”

 FPR in general:
 Easily Applied
 Non-traumatic
 Effective & Efficient
 When performed properly patients report immediate relief of point tenderness/pain.

 Treatment:
 Classified into two categories:
1) one directed at normalization of palpable abnormal tissue texture
2) to influence deep muscle involved in joint mobility
1) FPR - L3 NSLRR:
 Dx: L3 NSLRR or Left-Sided Erector Spinae Muscle Hypertonicity
 The patient lies prone on the table
 Use a pillow to flatten the curve
 Monitor L3 or hypertonic tissues (Fig. 12.18)
 Crosses the patient's right ankle over the left (right lumbar rotation) and
grasps the patient's right knee while sidebending the patient's legs to the
patient's left (Fig. 12.19)
 Then reposition the right hand to grasp the patient's right thigh and
rotates to the right until you reach maximum tissue relaxation
 Directs a force dorsally (toward ceiling) and toward external rotation
(white arrow, Fig. 12.20)
 Telescoping compression through femur to L spine dysfunction
 Wait 3-5 seconds and return to neutral passively either in/direct
 Recheck

2) FPR - Lumbar FRSright Seated:


 Dx: L3FRSR
 Straighten lumbar as a whole (flexion)
 Add some more flexion to L3-4
 Add a compressive, distraction or torsional force to L3
 Rotate the right until you reach maximum tissue relaxation while
monitoring paraspinals on the side of lumbar rotation
 Sidebend right until maximum tissue relaxation (softening) while
monitoring paraspinals on the side of lumbar rotation
 Wait 3-5 seconds and return to neutral passively
 Recheck

 Contraindications:
 Indication:
 Myofascial or articular somatic dysfunction
 Relative Contraindications:
 Moderate to severe joint instability
 Herniated disc where the positioning could exacerbate the condition
 Moderate to severe intervertebral foraminal stenosis, especially in the presence of radicular symptoms
at the level to be treated if the positioning could cause exacerbation of the symptoms by further
narrowing the foramen
 Severe sprains and strains where the positioning may exacerbate the injury
 Certain congenital anomalies or conditions in which the position needed to treat the dysfunction is not
possible (e.g., ankylosis)
 Vertebrobasilar insufficiency
 Jones Strain/Counterstrain:

 Counterstrain Neurophysiology:
 As with FPR, the primary neurophysiologic mechanism affected by counterstrain is thought to be the
relationship between Iα-afferent and γ-efferent activity
 If the dysfunctional segment is positioned appropriately, the fibers may return to normal length, which
decreases tension in the fibers
 This reduced tension in the area of the muscle spindle eliminates the afferent excitatory impulses
 This “quiets” the gamma motor gain, reducing the stretch stimuli, and eliminates the reflex activation of the
α-motor neuron
 This allows the tension and hypertonicity of the muscles to “reset”

 The Tender Point:


 Small edematous area roughly the size of a fingertip
 Painful to palpation
 Anterior or posterior
 Located at:
 Bone-tendon junction
 Musculotendonous junction
 Body of the muscle
 Related dermatome
 Usually located in the body of the antagonistic muscle (hyper-shortened muscle)

 Strain-Counterstrain Essentials
 Use Flexion or Extension (translate to localize)
 Have tender point at the apex of the curve
 SB & R according to Rx formula (for Type I and Type II dysfunctions - remember this is indirect)
 Shutdown the tender point at least 70%
 This position is called the position of comfort (subjective) or mobile point (objective)
 Tender point: Maintain light contact
 Hold positioning & tender point for:
 90 seconds: everything except ribs
 120 seconds: Ribs
 Recheck tenderness during treatment
 If you feel a therapeutic pulse fine tune your position
 Slowly reposition the patient and don’t let them reposition themselves!!!

 Anterior Lumbar Jone’s Points:


 TENDER POINTS
 A.S.I.S. ( L-1 )
 A.I.I.S ( L 2,3,4 )
 PUBES ( L-5 )
 Posterior Lumbar Jones’ Points:
 Counterstrain - Tender Point Location Proposal:

 Flexed Dysfunction - Anterior Jones point:

 Extended Dysfunction - Posterior Jones point:

 Counterstrain - BOARD STRATEGY:


1) IS THE T.P AN ANTERIOR OR POSTERIOR POINT
 IF ANTERIOR = FLEXED
 IF POSTEROR = EXTENDED
2) T.P. IS OVER THE OPEN FACET PAIR [ RIGHT ]
 THEN ANTERIOR Dx = FRSL
 THEN POSTERIOR Dx = ERSL
3) 3) FOR THE S/CS POSITIONING, PUT IN THE POSITION OF THE POSITIONAL DIAGNOSIS TO SHUT DOWN THE TENDER POINT
 Piriformis Syndrome:
 Neuromuscular condition characterized by hip and buttock pain
 Most frequently during the 4-5th decades
 Incidence rates among patients with low back pain vary widely, from 5% to 36%
 Muscle acts as an external rotator, weak abductor, and weak flexor of the hip. Provides postural stability during
ambulation and standing
 Attachments:
 Anterior surface of the sacrum
 Attaches to the superior medial aspect of the greater trochanter
 This syndrome is often overlooked in clinical settings because its presentation may be similar to that of lumbar
radiculopathy, primary sacral dysfunction, or innominate dysfunction

 May have a peripheral neuritis of the sciatic nerve caused by an abnormal condition of the piriformis muscle
Symptoms:
 Pain with sitting, standing, lying >15 min
 Pain and/or paresthesia buttocks, may radiate down posterior leg,
usually stopping above the knee
 Pain with rising from seated position
 Pain worse with internal rotation of leg
 Pain improves with ambulation
 Microtrauma
 “Wallet Neuritis”
 Toilet sitting
 Macrotrauma
 Fall
 Injection complication
 Ischemia
 Biomechanical
 Postural
 Somatic dysfunction
 Piriformis Syndrome: Strain-Counterstrain:
 Tenderpoint is usually in the belly of the muscle
 Location can be found ½ the distance between the Sacral base and ILA, then ½ the distance between this
point and the Greater Trochanter

 Piriformis Counterstrain:
 With patient prone locate and monitor the tender
point
 flex the hip on the dysfunctional side to ~135*,
 while monitoring the tender point add external
rotation and ABduction until you achieve a 70%
reduction in pain
 Hold for 90 seconds then return to neutral
 Recheck
 Psoas Syndrome:
 A neuromuscular condition characterized by pain in lower back and may
radiate to hip or groin
 Cause by muscle dysfunction due to spasm or strain
 Shortened muscle (i.e. sitting for prolonged period; running hills, sit ups
with legs extended)
 Organic causes (malignancy, AAA, abscess, appendicitis, hernia, prostatitis,
diverticulitis, OA)

 Flexion deformity of leg


 + Thomas test
 Leg length discrepancy
 Short leg on dysfunctional side
 Lumbar lordosis
 Spasm of contralateral piriformis
 Pelvic shift to opposite side
 Lumbar dysfunction
 Typically flexion dysfunction of L1 or L2
 Compensatory extension dysfunction in L-S spine
 Sacral dysfunction
 Rotate away from dysfunctional side

 Maverick Points:
 Roughly 5% of counterstrain tender points will not respond to the typical pattern of treatment
 Try putting the patient in the opposite position and treating the tender point
 Or
 Put the tender point in it’s position of ease and treat it