5 minutes: Attendance and Breath of Arrival. 50 minutes: Problem-Solving: Back

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1 Low Back Pain

2 5 minutes: Attendance and Breath of Arrival 50 minutes: Problem-Solving: Back

3 Punctuality- everybody's time is precious: o o Be ready to learn by the start of class, we'll have you out of here on time Tardiness: arriving late, late return after breaks, leaving early The following are not allowed: o o o o o o Bare feet Side talking Lying down Inappropriate clothing Food or drink except water Phones in classrooms, clinic or bathrooms You will receive one verbal warning, then you'll have to leave the room.

4 Low Back Pain

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6 Z-joint dysfunction Neuromuscular dysfunction Sacroiliac joint dysfunction (not addressed here) Herniated disc (not addressed here) Systemic disorders (not addressed here) Tumors or infections (not addressed here)

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8 Z-joint dysfunction Lumbar hyperlordosis overloads the Z-joints causing joint capsule and synovial inflammation, and chondromalacia.

9 Zygapophysial joint (AKA: facet joint, or Z-joint) Synovial joint between the superior articular process of one vertebra and the inferior articular process of the vertebra directly above it.

10 Chondromalacia Degeneration (softening) of articular cartilage. Most common occurrence is on the underside of the patella, called chondromalacia patellae.

11 How would you characterize the pain of Z-joint dysfunction? Nonspecific, deep, and achy Localized in a paravertebral area, unilaterally or bilaterally Worse in the morning Relieved by repeated motion Not worsened with coughing or laughing

12 What activities typically exacerbate the pain of Z-joint dysfunction? Rest Hyperextension Twisting Stretching Lateral bending

13 Why is Z-joint dysfunction more common in lumbar vertebrae? Z-joints are partial load-bearing joints, and Vertebral extension increases the load carried by Z-joints, and Lumbar vertebrae are already in extension due to their lordotic curve

14 What are some traditional treatments for Z-joint dysfunction? o NSAIDs and cryotherapy Variable effectiveness: inflammation is not always present Long term use may lead to GI tract and cardiovascular risks o Instruction in body mechanics, stretching, and strength training Effective: if done regularly to reduce lumbar lordosis o Corticosteroid injections Not effective

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16 Neuromuscular Involving nervous and muscle tissues. What are some causes of neuromuscular dysfunction? o Trauma o Fatigued muscles that are suddenly and awkwardly overloaded during a combined lateral flexion and rotation motion. o Dysfunctional coordination between muscle recruitment and fascial tension.

17 What are possible complications of neuromuscular dysfunction? o Postural stress in standing and sitting positions o Altered movement patterns: Restricted motion between two vertebral segments can increase or decrease motion at other segments. This lack of proper vertebral coordination leads to a mechanical overload and neuromuscular dysfunction of numerous muscles.

18 What are some traditional treatments of neuromuscular dysfunction? o Bed rest Not effective: more detrimental than helpful Provides pain relief Causes muscle splinting and range of motion limitations May lead to deep vein thrombosis in the lower extremity o NSAIDs Variable effectiveness: inflammation is not always present Long term use may lead to GI tract and cardiovascular risks

19 What are some traditional treatments of neuromuscular dysfunction? o Corticosteroid injections Variable effectiveness: inflammatory and pain management o Instruction in body mechanics, stretching, and strength training Effective: if done properly and regularly

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21 Prone Superficial fascia myofascial release Lumbar erector spinae Lift and roll BMT, and Fists down erectors Lumbar erector spinae Swedish Lumbar erector spinae deep longitudinal stripping Quadratus lumborum deep longitudinal stripping Quadratus lumborum trigger point deactivation Lamina groove deep longitudinal stripping Sidelying Quadratus lumborum pin and stretch Prone Quadratus lumborum active-assisted stretch Iliopsoas active-assisted stretch

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23 Superficial fascia myofascial release o Assess the fascia before and after to track effectiveness o Arms crossed: place hands 10 inches apart on either side of the spine o Apply a light degree of pulling force between the hands o Hold. Wait for a subtle sensation of tissue release or a working sign o Slowly release and repeat (between the sacrum and T10) Lumbar erector spinae Lift and roll BMT, and Fists down erectors o Lift and roll BMT (between the sacrum and T10) o Fists down erectors

24 Lumbar Swedish o Effleurage, wringing, and pulling (between the sacrum and T10) o Tissues must be thoroughly warmed and softened before proceeding Lumbar erector spinae deep longitudunal stripping o Use fingertips or thumbs to strip longitudinally and superiorly o Work in 2-4 inch sections. Pause and repeat in areas of tension o Progressively work more deeply as tissues soften

25 Quadratus lumborum deep longitudinal stripping o Iliac crest diagonally to the transverse processes o Iliac crest superiorly to the 12 th rib o Transverse processes diagonally to the 12 th rib (from the opposite side of the table) o Pause and repeat in areas where tension is palpated or reported Quadratus lumborum trigger point deactivation o Use fingertips or thumbs to target areas palpated or reported tension o Use the steps of the fulcrum to melt for about 10 seconds each

26 Lamina groove deep longitudinal stripping o Use fingertips with one hand stacked on the other o Longitudinally and superiorly, work in 2-4 inch sections. o Pause and repeat in areas where tension is palpated or reported o Progressively work deeper as tissues soften

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28 Note: Side-lying position draping o Keep the client fully covered with sheet and blanket

29 Quadratus lumborum pin and stretch o May exacerbate symptoms. Only use in non-acute stages o Instruct client: Lie with hips angled toward the side of the table Bottom knee slightly flexed Top leg hanging off the table behind you o Move the blanket out of the way to gain access to the QL o Support enough of the weight of the hanging leg so that quadratus lumborum is not engaged o Do the QL portion of Nine Points: Engage a point Remove your support of the hanging leg Instruct the client to slowly lower their leg Encourage QL stretch by pressing inferiorly on the ilium

30 Quadratus lumborum active-assisted stretch o May exacerbate symptoms. Only use in non-acute stages o Instruct client: Bottom knee slightly flexed Top leg hanging off the back of the table Grasp the top edge of the table with your top hand to stabilize the torso and further stretch the lateral trunk muscles Inhale and hold your breath Draw your hip up toward your ribs (hip hike) Hold this contraction for 5 seconds Slowly release the breath and the contraction Move the iliac crest away from your ribs Tell me when this feels like a good stretch o Press the hip away from the ribs with both hands o Hold for 3 of your breath cycles o Repeat the Contract-Relax-Stretch two more times

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32 Iliopsoas active-assisted stretch o Instruct client to: o Lie with one hip angled toward the side of the table o Pull your inside knee up into your chest and hold it there (to reduce Z-joint compression) o Hang your other thigh off the side of the table o Inhale and hold your breath o Using 50% strength, lift your hanging leg against my resistance and hold for 5 seconds (isometric hip flexion) o Slowly lower your leg as you release your breath and the contraction o Let me know when this stretch feels good o Wait 1 second and then press the thigh down to stretch the iliopsoas o Hold this for 3 of your breaths o Repeat the Contract-Relax-Stretch two more times

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34 o Restore proper joint biomechanics without increasing further trauma. o Stretching can be very helpful, especially if performed after massage. o If symptoms get worse as a result of treatment, cease that approach and reinvestigate the problem. You may need to refer the client to a more qualified practitioner for further evaluation.

35 o Pay close attention to the pain reported by the client o When in doubt about the cause of Low Back Pain, refer that client to a more qualified practitioner for further evaluation o This treatment can dramatically alter muscular proprioception resulting in spasms in an easily overloaded muscle. Have the client move slowly and carefully when first getting up from the massage table and for a short time afterward.

36 Low Back Pain

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