Rotational Forces : Their impact; our treatments Lee Stang, LMT, LMBT, BCTMB NCBTMB Provider: 450217-06 bridgestohealthseminars.com bthseminars@gmail.com 860.985.5834 Facebook.com/BridgesToHealthSeminars Bridges To Health Seminars 2015 Page 1
Rotational Forces: their impact, our treatment 1. Let s move through it: a. Exercise 1. i. Walking ii. Bending iii. Reaching iv. Bending and rotation 2. Small group analysis: a look at some athletes a. Exercise 2: Look at your assigned picture(s) and answer these questions: i. What is rotating? ii. What muscles are involved: what engages; what lets go? iii. What boney structures are moving or not? iv. What can restrict these motions? (be specific) b. Large group discussion of findings. 3. Rotation starts at the spine: a closer look: a. Exercise 3: seated or standing place thumbs on your transverse processes (tps) of lumbar spine: i. Laterally flex to the left then right; what happens to your thumbs? 1. When L lateral flex you R rotation OR 2. When R lateral flex you L rotation ii. Forward bend and laterally flex to left then right; what happens to your thumbs? 1. When forward bend and L lateral flexion you L rotation 2. When forward bend and R lateral flexion you R rotation iii. Extend the spine and laterally flex to the left then right; what happens to your thumbs? 1. Extend and flex L = L rotation 2. Extend and flex R = R rotation ** Lateral flexion (side bending) and rotation of the vertebra ALWAYS happens together This is referred to a coupling. Bridges To Health Seminars 2015 Page 2
4. Coupling: means the vertebra bends and rotates together a. Type 1 motion = coupled to opposite side: ie. Side bend L, rotate R b. Type 2 motion = coupled to same side: ie. Side bend L, rotate L c. In Lumbar and Thoracic Spine: i. Lumbar spine side bends more than it can rotate ii. Thoracic spine rotates more than it can side bend ** Key issue is vertebra can get stuck in this rotated position; often due to tightness in muscles in the area that are holding them in the rotated position. Locating vertebra that are rotated: Pressure is gentle but firm and consistent Pressure into tissue within and around the lamina groove Don t wiggle around; sink in until the bone stops you 5. Exercise 4: With partner seated on table: a. Place thumbs just lateral to spinous process of L5. b. Sink into tissue staying horizontal with each other c. Note position of thumbs when you have sunk into tissues to the tps. d. Note if one side is more pronounced than the other. Note which vertebra. e. Move up and down the spinal column looking and feeling for a bump: A vertebra that is more posterior on one side. This is a rotated vertebra. Make note of it. f. When talking about the rotation it is said to be rotated to the side you feel the bump on: ie. R bump, R rotation. Note rotation in vertebra: Vertebra number: ie T10 Rotated Direction: Left or Right Bridges To Health Seminars 2015 Page 3
Addressing the rotation: No manipulations No high velocity thrusts Goal: unwinding and releasing soft tissue that holds vertebra in rotation while indirectly affecting boney structures that these tissues may be holding. 6. Exercise 5: Client seated: Find a rotated vertebra a. Place thumbs in the laminal groove and feel (and look) for the tp bump on one side and an indent on the other b. Sink into the side that is indented and hold this pressure (about 1 lb). c. Hold pressure until you feel tissue soften and release i. May feel energy, vertebra rotating; vertebra above or below moving. d. When tissue softens, release slowly, count to 20 to give it time to settle then recheck the rotation of the vertebra e. Repeat if it remains rotated. i. If it does not de rotate it may be a facet issue. Note the vertebra. Facets: Key vertebral landmarks: Spinous process Transverse processes Lamina Facets: articulating surfaces o Synovial joints o Face in different directions o Open when we flex forward o Close when we extend back o Can be stuck or fixed open or closed Facet and vertebra movement with forward flexion and extension: Forward flexion = facets open; vertebra slides slightly superior and anterior to the vertebra below it. Extension = facets close; vertebra slides slightly inferior and posterior to the vertebra below it. With facet restrictions one side stays in place and the other side pivots around it causing improper movement of the vertebra. Bridges To Health Seminars 2015 Page 4
Addressing facet restrictions: 1. Exercise 6: Client is seated on table. Select a vertebra that did not de-rotate in the last exercise OR just select a thoracic vertebra OR go to an area of discomfort in your partner (in thoracic region) a. STEP ONE: select the side you feel is stuck closed (Remember you will feel the bump as it is side bent and rotated to the bump side closing the facet) i. Have client bend flex forward. ii. Place your elbow, knuckle or thumb in the lamina groove just above that facet. iii. Apply slow but firm pressure until you sink in and cannot go any further. iv. Hold this as client breathes until you feel tissue soften and release. v. May have client move in and out of flexion as you maintain pressure. vi. Release tissue; have client come up to neutral, count to 20 allowing things to settle, reassess for the rotated vertebra. If it remains rotated go to step two. b. STEP TWO: move to the other side of this vertebra to the side you feel might be stuck open. i. Have client extend back. ii. Place your elbow, knuckle or thumb in the lamina groove just above that facet. iii. Apply slow but firm pressure until you sink in and cannot go any further. iv. Hold this as client breathes until you feel tissue soften and release. v. May have client move in and out of extension as you maintain pressure. vi. Release tissue; have client come up to neutral, count to 20 allowing things to settle, reassess for the rotated vertebra. vii. May repeat each of these steps as necessary. KEY POINTS: Facets fixed closed = client flexes the spine Facets fixed open = client extends the spine When palpating: Side with prominent transverse process (the bump) facets are closed Side with the indented transverse process facets are open Bridges To Health Seminars 2015 Page 5
Rotational Forces: their impact, our treatment: Soft Tissue Release Key Muscles affecting Rotation: Thoraco/lumbar fascia Spinalis, Longissimus, Iliocostalis Laminal groove muscles: Rotatores, Multifidi, Intertransversarii, Interspinalis Quadratus Lumborum, TFL, Adductors Rectus abdominis fascia Psoas, Iliacus Start with more superficial work on the tissues of the back then move into the deeper tissues. We will look at work in side lying, prone, supine and seated. 1. Thoracolumbar fascia: myofascial spreading a. Client position: Prone b. Therapist position: side of table at level between clients hip and knees c. Hand position: one hand full palm resting on iliac crest; one hand full palm resting on lower ribs. Can use crossed hands. d. Technique: pin tissue in inferior direction at ilium i. : Spread and stretch tissue away from the pinned hand toward upper back e. Variation: work opposite side of body i. : Pin tissue at ilium on side therapist is on. ii. : Spread tissue on diagonal across the body toward opposite scapula. f. Variation: work opposite side of body i. : Start on far side of spinous processes and transvers the lumbar fascia ii. : Reach across body with one hand and around pelvis and grasp ilium at ASIS iii. : Pull pelvis into rotation as spread across QL and lumbar fascia. Stay superficial as you work fascia g. Variation: forearm into lumbar fascia i. : With no additional pressure except the weight of your forearm rest forearm between last rib and ilium. Can move slightly but wait for tissue to warm and soften. Sink in further as tissue releases. Do not apply further pressure. Bridges To Health Seminars 2015 Page 6
2. Erector Spinae: This includes longissimus, iliocostalis and spinalis muscles a. Client position: Prone b. Therapist position: Opposite side of table for broadening, friction and wiggle/lengthen techniques; head of table for deep stripping c. Hand position: varies from fingers to knuckles; may also use tools d. Muscle Focus: Longissimus Attaches to: Spinous process lumbar vert. Transverse process Thoracic vert. As work start at SP in lumbar region then move out to TP of thoracic vertebra Extension and lateral flexion of spine Iliocostalis Attaches to: Sacrum and iliac crest. Transverse processes of lumbar vert. and ribs 6-12. As it comes up the back it moves away from the spine Extension and rotation of spine Spinalis Thoracis Attaches to: Spinous process T2-T8 and T10-L3. It remains close to the spine Extension, lateral flexion and some rotation Bridges To Health Seminars 2015 Page 7
Positioning of hands and technique: Palpating Longissimus: Start: locate spinous process in lumbar region L5. Fall off SP opposite side. Sink lightly into tissue. This muscle is more superficial. A broad muscle about 1-1.5 inches across. As move up spine from L2 T3 start palpation about.5-1 inch from spine as longissimus attaches now to the transverse processes. Technique to release: 1. Lumbar region: spread tissue 1-1.5 inches away from SPs. 2. Thoracic region: start at TPs and spread tissue 1 inch going away from TPs. 3. Friction: feel ropey bands and multi-direction friction. 4. Wiggle-strip: as you friction wiggle fingers in between fibers using both hands. When you sink into longissimus layers strip the tissue in small sections by moving your fingers away from each other. 5. Movement: can incorporate anterior/posterior tilt 6. Full length stripping GET SPECIFIC Palpating Iliocostalis: Start: locate SPs of sacrum and the iliac crest. TP L5-T6. Fall off opposite side SP. Sink lightly into tissue. This muscle is more superficial. Starts on the sacrum L5-L1 starts at TPs. From T12-T6 start out on the ribs about 2 inches from the SP as it attaches to the ribs not the vertebra. Technique to release: 1. Sacrum region: Spread tissue away from SP on sacrum 2. Circular friction along sacrum and iliac crest. 3. Lumbar region: Spread out from TPs 1.5-2 inches 4. Rib region: Start about 2 inches from SPs. Spreading and friction from T6. 5. Wiggle-strip: as you friction wiggle fingers in between fibers using both hands. When you sink into Iliocostalis layers strip the tissue in small sections by moving your fingers away from each other. 6. Movement: can incorporate anterior/posterior tilt. 7. Movement: rotation of pelvis. Grasp opposite ilium at ASIS. Gently rotate as work across the fiber along the iliac crest. 8. Full length stripping. GET SPECIFIC Palpating Spinalis: Start: locate SPs T10-L3. Fall off opposite side of SP. Sink lightly into tissue within lamina groove. It is in lamina groove Locate SP T2-T8. Sink lightly into tissues within lamina groove. Spread tissue away from SPs staying within the lamina groove Techniques to release: 1. Lumbar region: spread tissue away from SPs staying within lamina groove. 2. Thoracic region: spread tissue away from SPs staying within lamina groove. 3. Friction: feel ropey bands and multi-direction friction. 4. Wiggle-strip: as you friction wiggle fingers in between fibers using both hands. When you sink into spinalis layers strip the tissue in small sections by moving your fingers away from each other. 5. Movement: Lumbar region can incorporate anterior/posterior tilt. 6. Movement: Thoracic region; thoracic extension by lifting head and shoulders off the table. GET SPECIFIC Bridges To Health Seminars 2015 Page 8
3. Laminal groove muscles: rotatores, multifidi, intertransversarii Multifidi Attaches to: Sacrum and TPs of vertebra to Spinous process of vertebra above it: L5-C2 Extension, ipsilateral lateral flexion, contralateral rotation Intertransversarii Attaches to: From transverse process to transverse process Lateral flexion of the spine Rotatores Attaches to: Lamina of one vertebra to the transverse process of the one below it through thoracic region. Contralateral rotation of the spine (opposite side) Positioning of hands and technique: For all these muscles: work opposite side of the table, sink into the lamina groove. Focus work in specific direction to isolate specific muscles. Technique Multifidi: Start: locate spinous process in lumbar region L5. Fall off SP to opposite side. Sink lightly into tissue. Spread tissue away from spine moving staying within SP and TP. Work your way up and down the spine Technique to release: 1. Myofascial spreading. 2. Friction: feel ropey bands and multi-direction friction. 3. Wiggle-strip: as you friction wiggle fingers in between fibers using both hands. Strip the tissue in small sections by moving your fingers away from each other. Technique Intertransversarii: Start: locate SPs of lumbar vertebra. Fall off SP to opposite side. Sink lightly into tissue and follow it out to the TP. Work with tissue between the TP; that connects one TP with the one above or below it. Technique to release: 1. Circular friction between transverses processes. 2. Wiggle-strip: as you friction wiggle fingers in between fibers using both hands. When you sink into intertransversarii layers strip the tissue in small sections by moving your fingers away from each other. Move from TP to TP Palpating Rotatores: Start: locate SPs C5-T12 Fall off SP to opposite side sinking into lamina. Angle technique toward to TP below the vertebra you start on. Spread tissue away from SPs staying within the lamina groove Techniques to release: 1. Myofascial spread tissue away from SPs toward lower TPs staying within lamina groove. 2. Friction: feel ropey bands and multi-direction friction. Bridges To Health Seminars 2015 Page 9
4. Stretch for thoracic rotation: 1. Diagonal stretch of Thoraco/lumbar region a. Client position: Supine with legs straight and arm across chest (opposite arm from where therapist is standing) b. Therapist position: standing at side of table c. Hand position: one hand on opposite hip to stabilize; one hand reach over opposite shoulder and placing hand along opposite erector group on lower thoracic, upper lumbar region; rotate client toward you to reach this. d. Stretch: as client exhales therapist leans toward feet pulling client into trunk flexion and rotation e. Variation: add PNF having client gentle push into extension against therapist hand Soft Tissue Treatment strategies: Side-lying 1. Quadratus Lumborum lengthening a. Client position: Side lying with bottom leg bent, top leg straight b. Therapist position: Posterior side of table, level with hips c. Hand position: fingers sliding around posterior ilium into attachment of QL at ilium; d. Technique: sink into tissue and strip along length of QL e. Movement: passive adduction then active adduction of leg off the table putting QL on stretch f. Add stretch: let leg fall off the table into further adduction; grasp ilium and pull down further stretching QL; place client arm over head to get deeper stretch through QL and Latissimus 2. Adductors a. Client position: side-lying with bottom leg straight, top leg bent b. Therapist position: side of table behind client c. Hand position: palpate gracilis on bottom leg; work with frictions and stripping gracilis, brevis and magnus (direction: gracilis and posterior) d. Movement: passively lift bottom leg into adduction while compressing the tissues NOTE: With QL tightness the opposite adductor group is often also hypertonic: example R QL tightness often translates to L adductor tightness. Bridges To Health Seminars 2015 Page 10
5. Soft Tissue Treatment strategies :Supine 1. Abdominal fascia, a. Client position: Supine b. Therapist position: side of table c. Muscle Focus: i. Superficial Abdominal Fascia a. Client Position: Supine with feet flat on table b. Technique: Fascial Release: place fingers on lower part of rectus and pull tissue toward head. Work Rectus in sections. Release fascia up to Rib 5. ii. Deep Abdominal Fascia a. Identify Rectus Abdominal muscle. Slide fingers into either side of the RA muscle. Lift tissue up and in superior direction, fractioning and spreading. b. Work slowly as this can be painful both physically and emotional. 2. Internal Obliques: a. Client position: Supine with feet flat on table b. Therapist position: opposite side of the table c. Technique: work opposite side of the body stripping and pinning tissue as client rotates trunk with either pelvic or shoulder movement; d. MET resist trunk contralateral rotation from the shoulder 3. External Obliques: a. Client position: Supine with feet flat on table b. Therapist position: opposite side of the table c. Technique: work muscle on same side of the table; lifting opposite hip while pinning or stripping tissue d. MET with hip rotation on same side Bridges To Health Seminars 2015 Page 11
4. Psoas/Iliacus a. Psoas 1: i. Client position: supine, with knee resting over therapists knee ii. Therapist position: side of table with knee on table iii. Hand position: one hand grasps ankle of client; one hand resting on iliacus. iv. Movement: passive gentle movement of leg as sink into the tissue. Pump handle: lift of leg over knee while sinking into psoas. b. Psoas i. Client position: supine, leg flexed at the hip and knee with foot on table ii. Therapist position: side of table, hip level iii. Hand position: one hand supporting knee and providing movement; one hand resting on iliacus. 5. Movement: passive gentle movement of leg as sink into the tissue. Once accessing psoas client actively extends and flexes leg. Seated Rotational Release a. Client position: seated on side of table with arms crossed across the chest b. Therapist position: next to client with one knee on table one foot on floor c. Hand Position: Anterior hand reach across and support opposite shoulder (anterior); posterior hand engage Paraspinals on opposite side of vertebral column d. Movement: Client rotates toward the therapist as therapist broadens tissue along lamina groove or sinks into lamina with gentle pressure e. Movement variation: Therapist fingers sink into lamina groove as client rotates away from therapist f. MET: resist rotation with pressure on anterior shoulder then posterior scapula Bridges To Health Seminars 2015 Page 12