Connective Tissue Techniques and Stretching Procedures for Lumbar Spine

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BOOK EXCERPT
Connective Tissue Techniques
and Stretching Procedures
for Lumbar Spine
Howard W. Makofsky, PT, DHSc, OCS

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Thoracolumbar Junction Release

CHAPTER 18

This release (Figure 18-1) is an important myofascial release technique for both the thoracolumbar junction and the posterior diaphragm. The therapist’s hands are placed lightly on either side of the prone patient’s thoracolumbar junction with the thumbs close to the spinous processes and the fingers pointing cephalward. The “shear-clock” method is again utilized to identify impairment in mobility of the skin and superficial fascia (indirectly, the deep fascia as well through its connection to the basement membrane of the dermis). Once the area of greatest restriction (AGR) is located, the therapist uses either indirect or direct treatment technique to obtain the desired “release” (the 4 Ms procedure described in Chapter 5 is applicable to either approach).

Ward¹⁵ describes a direct myofascial release technique in which he employs tension, traction, and twist to the tissues between the right and left hands for 10 to 30 seconds. As softening and elongation occur (ie, myofascial “release”), the therapist follows behind in search of new motion barriers. Tension is achieved through light compression, traction involves a perpendicular stretch of the paraspinal tissues, and twisting is achieved through a clockwise/counterclockwise rotation of the hands. These three “prerelease” forces cause a “winding up” of the tissues, which sets the stage for myofascial “unwinding.” The Ward approach is actually a combination technique that begins direct and ends indirect.

Iliopsoas Fascial Technique

Understanding the actions of the iliopsoas muscle serves as a useful guide in both the eval‎uation and intervention of patients with lumbar-pelvic-hip impairment. The actions are as follows:

• Hip flexion with a secondary role in external rotation and abduction.
• In erect posture, upper lumbar extension with lower lumbar flexion (ie, exaggerated lumbar lordosis with anterior pelvic tilt).
• In the forward bent position, the iliopsoas contributes to lumbar flexion.
• A unilateral contraction laterally flexes the lumbar spine to the ipsilateral side and by compression, contributes to spinal stability.
• Unilateral tightness may also contribute to a type 2 impairment such that the inferior component of the motion segment is laterally translated to the ipsilateral side. For example, left-sided tightness at L3,4 causes lateral translation of L4 to the left with overturning of L3 into flexion, rotation, and side bending to the right (ie, FRS right at L3,4).

In the author’s opinion, it is imperative that the status of the iliopsoas muscle be assessed in all low back patients. In the pelvic girdle section of this textbook, the length of the iliopsoas will be assessed and treated as one component of the TRI muscle stretch (tensor fascia latae, rectus femoris, and iliopsoas). At this point, however, our focus will be on the application of a direct fascial technique with the muscle on slack and under stretch.

As illustrated, the patient is positioned in side lying with the involved side up. The initial phase of this technique (Figure 18-3a), involves passively placing the upper-most hip in flexion and external rotation in order to relax the iliopsoas for greater access. While adjusting the lower limb for maximal relaxation, the other hand monitors the psoas approximately 2 inches lateral to the umbilicus. In this position, an isometric contraction of the hip flexors ensures that the iliopsoas has been located. Following deep tissue massage in the muscle’s slackened state, the iliopsoas is then placed under stretch by extending the lower limb at the hip (Figure 18-3b). In this position, the therapist again applies deep tissue massage in conjunction with postisometric relaxation, which helps to decrease the resting tone of the iliopsoas muscle (the therapist may have the patient hold the bottom leg in hip and knee flexion for enhanced counter stability of the pelvis).

Treating the muscle in both positions (ie, slackened or stretched) allows either an indirect or direct approach to intervention, depending on the state of tissue reactivity present (see Chapter 3 for a description of direct and indirect treatment methods).

Lumbosacral Junction Release

In order to “disengage” the lumbosacral junction and release abnormal soft tissue tension (Figure 18-4), the therapist’s cephalic hand is placed over the lower lumbar spine, while the caudal hand is placed over the sacrum with the heel of the hand on the sacral base. The therapist can approximate the two hands to perform an indirect myofascial “unwind” or place the tissues of the lumbosacral junction on maximal stretch and perform a direct technique against the restrictive barrier(s). A pillow can be placed under the patient’s abdomen to further decompress the region.

Sacrospinalis Stretch

Patients with McKenzie’s flexion dysfunction respond well to the sacrospinalis stretch (Figure 18-5). However, it is contraindicated in patients with posterior derangement of the lumbar spine.

With the patient placed in the “knees to chest” position, the therapist places his or her other hand under the patient’s sacrum with the fingers on the base and the heel of the hand over the apex. The stretch is accomplished by directing the lumbar spine into further flexion through the lower limbs as the sacrum is counternutated. A gentle postisometric relaxation often enhances the technique’s efficacy, providing that the patient’s symptoms are not exacerbated by this procedure.

Neural Mobilization

Butler^17,18 recommends that neural mobilization be viewed as another form of manual therapy similar to joint mobilization. In this regard, the treatment of signs and symptoms based on the severity, irritability, and nature of the impairment must be kept in mind at all times. The danger in presenting this material outside the context of the entire art and science of neural mobilization is that it be seen as a technique rather than as a comprehensive system involving clinical reasoning, problem solving, and a thorough understanding of the anatomy, physiology, and pathophysiology of neurobiologic structures. Having said that, we will proceed to using manual methods in order to restore the mechanical function of impaired neural tissues (intra- and extraneural impairment) in the lumbar-pelvic-lower limb complex. As with all manual therapy procedures, the goal remains the same (ie, “to restore maximal pain-free movement within postural balance”). Contraindications include irritable conditions, inflammation, spinal cord signs, malignancy, nerve root compression, peripheral neuropathy, and complex regional pain syndromes I and II.

Proximal Sciatic Nerve

The sciatic nerve is the largest nerve in the body, but actually consists of two nerves: the common peroneal and tibial, which are tightly bound together by connective tissue. The common peroneal nerve is a posterior branch of the sacral plexus originating from the lumbosacral trunk (L4 to S2); the tibial nerve is an anterior branch of the sacral plexus originating from the ventral rami of L4 to S3. Sites of potential proximal compression include the lower lumbar spine (eg, intervertebral disc, spinal canal, lateral recess, intervertebral foramina, etc), the piriformis muscle, and hamstrings. Because the sciatic nerve runs posterior to the hip and knee joints, the optimal means of inducing longitudinal tension is through the straight leg raise first described by Leseague in 1864.¹⁷ The leg is lifted upward, as a solid lever, while maintaining extension at the knee. To induce dural motion through the sciatic nerve, the leg must be raised past 35 degrees in order to take up slack in the nerve. Since the sciatic nerve is completely stretched at 70 degrees, pain beyond that point is usually of hip, sacroiliac, or lumbar spine origin. The unilateral straight leg raise causes traction on the sciatic nerve, lumbosacral nerve roots, and dura mater. Adverse neural tension produces symptoms from the low back area extending into the sciatic nerve distribution of the affected lower limb. To introduce additional traction (ie, sensitization) into the proximal aspect of the sciatic nerve, hip adduction is added to the straight leg raise (Figure 18-6). This is because the sciatic tract is lateral to the ischial tuberosity; therefore, adduction causes further tensing of its proximal aspect.

Prior to commencing neural mobilization, McKenzie’s derangement syndrome must be ruled out. Stretching nerve roots that are reacting to local compression is only indicated for examination purposes. Cyriax¹⁹ described the straight leg raise “painful arc” sign, which usually appears from 45 to 60 degrees. This sign, in which there is no pain above and below the point of adverse neural tension, implies that the nerve root momentarily “catches” against a small protrusion and then slips over it. In the presence of this finding or other indications of disc herniation, neural mobilization should not be performed. The purpose of neural mobilization is to restore normal function to impaired neural structures that were previously compressed, irritated, and inflamed. The intervention recommended is a “flossing” of the nerve in which gentle, short duration (1 second) and large amplitude passive movements are performed at the “feather edge” of the patient’s neural symptoms in an “on/off” fashion. In other words, a mild degree of discomfort is permitted during the momentary stretch (ie, “on” phase), which must completely abate when the tension is withdrawn (ie, “off” phase). The patient’s symptoms must be monitored at all times, and it is suggested that the patient be initially undertreated until the irritability of the impairment becomes apparent. Thirty to 60 seconds of on/off mobilization is a useful guideline for intervention.

Femoral Nerve

The femoral nerve is a branch of the lumbar plexus, which is formed by the ventral primary rami of L1, L2, L3, part of L4, and possibly T12. The femoral nerve continues medial to the knee as the saphenous nerve. The femoral nerve stretch was first described by Wasserman¹⁷ in 1919, who proposed it as a physical sign to explain anterior thigh and shin pain in soldiers. In 1946, O’Connell recommended the inclusion of hip extension.¹⁷

As with other nerve stretching maneuvers, the femoral nerve stretch (prone knee bend or Nachla’s test) can be used for both examination and intervention. There are two components to the nerve stretch:

• The uppermost part of the thigh is passively extended just short of producing lumbar spine extension. By creating tension in the iliopsoas, the upper lumbar nerve roots are put under traction

• The knee is then progressively flexed to increase femoral nerve tension by stretching the quadriceps femoris muscle. Pain in the anterior thigh may be of muscular or nerve origin. A careful history should help to delineate the problem.

Again, the neural flossing technique in an on/off fashion is recommended for adverse neural tension (Figure 18-7). The pelvis should be properly stabilized to prevent stress from being placed on the sacroiliac joint and lumbar spine (Yeoman’s test). The lateral femoral cutaneous nerve can be stretched by adding hip adduction to the extended hip and flexed knee. The saphenous nerve is stretched by placing the hip in extension, abduction, and lateral rotation while extending the knee and dorsiflexing/everting the ankle.

Common Peroneal Nerve

The common peroneal nerve (L4,5; S1,2) lies directly posterior to the proximal fibular head and, therefore, can be injured with posterior fibular head displacement and/or fracture of the fibula. Since supination of the ankle causes a posterior glide of the fibular head, a lateral ankle sprain can be a contributing factor to injury of the nerve.

To place the common peroneal nerve under tension, the hip is flexed and medially rotated, the knee is extended, and the ankle is plantar flexed and inverted (Figure 18-8). According to Butler,¹⁷ plantar flexion/inversion may be added before the straight leg raise (SLR), or at the completion of the SLR. Once again, the management of adverse neural tension involves a gentle on/off stretch of large amplitude at the onset of symptoms. The goal is to achieve functional gliding of the common peroneal nerve along its complete course from proximal to distal.

Tibial Nerve

The tibial nerve (L4,5; S1 to S3) is brought under tension with the addition of ankle dorsiflexion. This is because its terminal branches, the medial and lateral plantar nerves, course along the plantar surface of the foot and are therefore stretched by dorsiflexing the ankle. In addition to hip flexion, knee extension, and ankle dorsiflexion, the tibial tract can be further sensitized by everting the ankle, extending the toes, and stretching the plantar fascia (Figure 18-9). Butler states that ankle dorsiflexion may be added first and then the limb lifted, or performed at the limit of the SLR. The tibial nerve forms the largest component of the sciatic nerve in the thigh. Inferiorly, it descends through the popliteal space, passing between the heads of the gastrocnemius muscle to the dorsum of the leg, as the posterior tibial nerve, and into the ankle and foot. As the posterior tibial nerve traverses under the flexor retinaculum at the tarsal tunnel, it is subject to possible compression (ie, tarsal tunnel syndrome). As mentioned above, it then divides into the medial and lateral plantar nerves, which supply sensation to the sole of the foot and toes as well as supplying sensation to the foot joints and efferent fibers to the small muscles of the foot. When adverse neural tension is present, neural mobilization is gently performed for 30 to 60 seconds.

Sural Nerve

The medial sural cutaneous nerve, a branch of the tibial nerve, joins the lateral sural cutaneous nerve, a branch of the common peroneal nerve, to form the sural nerve (L5, S1, S2), which supplies the skin of the posterolateral part of the leg and the lateral side of the foot. According to Butler,¹⁷ “The sural nerve is a forgotten nerve and is responsible for far more symptoms than it is given credit for.” With practice, the sural nerve can be palpated along the lateral aspect of the foot, behind the lateral malleolus, and lateral to the Achilles’ tendon. The position of maximal sural nerve tension consists of hip flexion, knee extension, and ankle dorsiflexion followed by ankle inversion (Figure 18-10). Butler refers to this combination of movements as the sural nerve tension test. As with the other nerve tension tests, the same limb position is then transformed into a neural mobilization in the presence of impairment.

To further sensitize the tibial, common peroneal, and sural nerves, additional loading is made possible by adding cervical flexion, lumbar and thoracic side bending to the contralateral side, hip adduction, and medial rotation.