Kinesiology for Manual Therapies Chapter 16 Deep Tissue of the Low Back and Posterior Pelvis McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Learning Outcomes 16-1 Define key terms. 16-2 Locate on a human skeleton selected bony structures of the trunk, spine, and pelvic girdle. 16-3 Palpate bony landmarks and the muscles of the trunk, spine, and pelvic girdle on a partner. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Learning Outcomes (cont.) 16-4 Explore the origins and insertions of the muscles of the trunk and pelvic girdle on a partner. 16-5 Review general pathologies and conditions of the muscles of the trunk and pelvic girdle. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Learning Outcomes (cont.) 16-6 Discuss treatment protocol for conditions of sciatica, back-pocket sciatica, and piriformis syndrome. 16-7 Demonstrate safe body mechanics. 16-8 Practice specific techniques on the low-back and pelvic girdle muscles. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Learning Outcomes (cont.) 16-9 Incorporate dimensional massage therapy techniques in a regular routine or use them when needed. 16-10 Determine safe treatment protocols and refer clients to other health professionals when necessary. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Introduction 80 percent of the general population will experience back pain. 50 percent will feel relief from low-back pain within 2 weeks and 90 percent will recover within 3 months. Reoccurrences of back pain are likely, even within the same year. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Introduction (cont.) Sources of pain include muscles, tendons, ligaments, bones, disks, and facet joints. Conservative care includes rest, physical therapy, ergonomic evaluation of the work site, postural awareness, massage therapy, stretching, chiropractic, etc. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Introduction (cont.) Cryotherapy, the safe use of ice and exercise to reduce inflammation and acute responses, is useful for acute and subacute back pain. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Structural Perspectives of the Low Back and Pelvic Girdle The muscles of the back are layered and interconnected between the pelvic girdle, sides of the abdominal muscles, and occiput. The placement of the pelvic girdle anteriorly or posteriorly affects the spinal curvature and soft-tissue dysfunction of the back. Contracted muscles in the lower extremities contribute to the position of the hips. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Structural Perspectives of the Low Back and Pelvic Girdle (cont.) Structural perspectives provide the massage therapist reason enough to design individual treatments based on medical history, postural observations, and palpation of associated hypertonic soft-tissue. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Injuries and Overuse Syndromes Axial pain can be sharp or dull, constant or intermittent, and mild or severe and can be confined to the low back. Axial pain gets worse with certain activities, and is relieved by rest. Axial pain is mechanical in origin and benefits from conservative care approaches. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Injuries and Overuse Syndromes (cont.) Back pain can also be caused by kidney stones, bladder infections, tumors, and internal injuries. Back pain should be diagnosed by a physician to rule out internal conditions. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Injuries and Overuse Syndromes (cont.) Treatment Protocol Reasons for Referral: Fever and/or chills; nausea and/or vomiting History of cancer with recent weight loss Severe trauma Significant leg weakness Sudden bowel and/or bladder incontinence Severe continuous abdominal and back pain McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Injuries and Overuse Syndromes (cont.) Soft-tissue Issues Lifting items in an unbalanced position directly in front of the client with the back instead of the legs puts the erector spinae and latissimus dorsi at risk. Lifting off to the side of the body with the back may call the quadratus lumborum, erector spinae, and gluteus medius into action. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Nerve Complaints Radicular pain is unilateral, deep steady, and reproducible with certain activities, and follows involved dermatome. It can include numbness and tingling, muscle weakness, and loss of specific reflexes. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Nerve Complaints (cont.) Sciatica is an inflammation of the sciatic nerve and presents with radicular pain. Impingement can result from a herniated disk, foraminal stenosis, diabetes, nerve root injuries, or scarring from a previous spinal injury. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Nerve Complaints (cont.) Foraminal stenosis is a narrowing of the intervertebral space through which the spinal nerve exits. A herniated disk occurs when the gelatinous nucleus pulposus protrudes into or through the annulus fibrosus. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Nerve Complaints (cont.) Piriformis syndrome involves the entrapment of the sciatica nerve and the referral of pain down the lower extremity. Back-pocket sciatica is a painful condition caused by wearing a wallet in the back pocket affectively entrapping the sciatic nerve in sitting positions. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Nerve Complaints (cont.) Referred pain can be achy, dull, migratory, and intermittent with varied intensity. It can radiate from the low back to groin, buttock, and upper thigh. It is different from the referred pain of myofascial pain and trigger points. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Nerve Complaints (cont.) Myofascial pain is associated with soft tissue. It may or may not hurt at the location of the trigger point and is not linked to the distribution of a nerve. Myofascial pain is often treatable with conservative care. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Arthritis, Osteoarthritis, Degenerative Disk Disease, and Lumbar and Sacroiliac Subluxations The low back is vulnerable to degenerative disk disease and osteoarthritis. In the surgical procedure, a laminectomy, the posterior arch and spinous process of the midline of the vertebrae are removed freeing the spinal cord from stenosis. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Unwinding the Muscles of the Low Back: Prone or Supine? Educate the client with the correct sequence. Positioning should be part of the expertise of the therapist aiming to make the treatment more successful. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Unwinding the Muscles of the Low Back: Prone or Supine? (cont.) Use the supine position first to unwind the head, neck, and shoulder soft-tissue areas. Attend to the comfort and support of the client and use an appropriate sequence. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Adequately prepare the entire back with introductory strokes of effleurage, compression, petrissage, and rocking along with myofascial strokes and stretches, elliptical movements, parallel thumbs, before using specific deep-tissue techniques. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle Prone Elliptical Movement of the Hips McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Myofascial Stretches and Techniques McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Myofascial Stretches and Techniques McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Elliptical Movement for Lower-Back Muscles McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Alternating Effleurage McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Figure Eight of the Low Back McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Petrissage External Oblique McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Edging the Hip McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Thumb Friction McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Deep Transverse Friction to the Erectors McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Forearm Effleurage to the Erector Spinae McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Trigger Points for Quadratus Lumborum McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Quadratus Lumborum Stretch McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Quadratus Lumborum Stretch McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont. ) Prone Erector Spinae Stretch McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Sacrum – Parallel Thumbs McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Deep Transverse Friction to the Sacrum McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Forearm Effleurage on the Posterior Crest McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Gluteals – Elliptical Movement on the Gluteals McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Gluteals – Elliptical Movement on the Gluteals McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Circular Effleurage on the Gluteals McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Anchor Hip and Separate Fibers McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Palm Compress Effleurage to the Gluteus Medius McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Closed-fist Stripping of the Gluteus Medius McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Deep Petrissage of the Gluteals McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Parallel Thumbs to the Gluteus Maximus McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Bent-knee Compression with Passive Movement McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Deep Transverse Friction the Tensor Fasciae Latae McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Deep Transverse Friction of the Anterior and Posterior Crest McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Deep Transverse Friction to the Piriformis McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Trigger Points in the Lateral Rotators McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Forearm Effleurage of the Sacrum and Crest McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Repeat sequence to the other gluteal region. Dimensional Massage Therapy for the Muscles of the Low Back and Pelvic Girdle (cont.) Prone Repeat sequence to the other gluteal region. Assess the success of the treatment. End with a full-back effleurage and ending strokes. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Chapter Summary This chapter discussed the structural perspectives of the low back and pelvic girdle and injuries and overuse syndromes including inappropriate lifting and gave reasons for referral for undiagnosed clients with specific signs and symptoms. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Chapter Summary (cont.) Nerve complaints were explored. Arthritis, osteoarthritis, degenerative disk disease, and lumbar and sacroiliac subluxations were reviewed. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Chapter Summary (cont.) Treatment protocol and sequence of the muscles of the low back and posterior pelvic girdle areas were outlined for unwinding these muscles. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Chapter Summary (cont.) Dimensional Massage Therapy techniques for the muscles of the low back and posterior pelvic girdle were depicted for the prone position. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Chapter Review The Chapter Review is divided into true and false, short answers, and multiple choice questions. The questions are designed for the students to test their knowledge. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Explore and Practice Activities in this section are for practice and demonstration. Every opportunity should be utilized to locate muscular attachments on as many different bodies as possible to support kinesthetic learning. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved

Explore and Practice Use the muscle cards and book in technique classes, for log hours, or for case studies for reference purposes. McGraw-Hill © 2011 by The McGraw-Hill Companies, Inc. All rights reserved