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LOW BACK & HIP UNIT MODULE 4 1 __________________________________________________________________ Welcome to Beyond Trigger Points Seminars, Low Back and Hip Unit Module 4 on the Thoracolumbar Erector Paraspinals, Abdominals and Serratus Posterior Inferior. This is Cathy Cohen. By the end of this lesson, you will be able to identify the trigger points and the dysfunctions occurring in these very important structural muscles. Our other learning objective is to differentiate between a somatovisceral versus a viscerosomatic effect. First, let's be clear on how these muscles are named. Collectively the muscle group along the spine is referred to as the paravertebral muscles. Our book labels the superficial group as the erector spinae and the deep group as the paraspinal muscles. So again, the superficial group we'll refer to as the erector spinae and the deep group as the paraspinal muscles. When I was developing my true beginner’s status in this profession, I made a bet with a chiropractor. My perception of the relative thickness between the superficial and the deep paraspinal muscles differed from his knowing. During a camping trip in the Shenandoah Valley, Virginia, I thought I had the perfect opportunity to win my bet. A farmer had donated a pig to roast and my fellow campers agreed to let me butcher the pig’s tenderloin. Those are the muscles along the pig’s spine. Well, just as my chiropractor friend said, the long fibered superficial muscles are relatively thinner than the short fatter diagonal muscles of the deep group. I lost ten dollars that day. On page 24 of the student study guide, the actions to list for the deep thoracolumbar paraspinals are: 1. Fine adjustments between the vertebral bodies. 2. Rotation These muscles span either one or two vertebral segments. The superficial thoracolumbar erector spinae group has four actions: 1. Extension 2. Side bending 3. Rotation 4. Check reins flexion to 45 degrees. BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM Putting Your Hands To Better Use © 2009 Cathy Cohen, LMT LOW BACK & HIP UNIT MODULE 4 2 __________________________________________________________________ Another way to say that is, they control the speed of forward flexion up to 45 degrees forward. So when the torso is pitched forward between 45 degrees and upright these muscles are working hard. In one study of 283 patients presenting to a chronic pain treatment program with benign low back pain, 96% of them had trigger points. On page 26 you are looking at those trigger points possibly responsible for a large percentage of the low back pain you see in your office. You’ll only know if you look for them. The trigger points in these muscles refer pain primarily to the back and sometimes into the buttocks. Going back to page 25, begin drawing the trigger points commonly located in these muscles. As you are drawing, keep in mind, trigger points can develop at different layers and at varying depths within the layers. When I’m working in this region, I’m asking myself what layer my pressure is contacting. By remembering the pain patterns, I can determine which group of muscles I’m on when I find a trigger point. If you can commit one pain pattern to memory now, I suggest memorizing the iliocostalis thoracis at the T6 level shown on picture A. This is a very common pain pattern, often described as a stabbing pain along the paravertebral border of the shoulder blade with a spillover into the chest. Sometimes your client won't even tell you about the pain complaint to the anterior side of their body unless you query them on it. They don't think it is related. The sensation feels like it’s moving through them from back to front. To find this point, strum the longitudinal running fibers of the iliocostalis thoracis with a cross fiber friction stroke. You’ll locate this trigger point a few inches above the inferior angle of the scapula. On picture B, the referral pattern of the trigger point off T 11 segment feels as if it’s moving in two opposite directions. Don't forget to draw the pain pattern into the abdomen area as well. The iliocostalis lumborum and the longissimus thoracis in pictures C and D both refer pain distally into the buttocks. The distance the pain refers from where your elbow is pressing will amaze your clients. Moving on to the picture of the multifidi and rotatores on page 28, you see how the basic pain patterns for the deep muscles are like little sunshine rays around the trigger point. The pain from these points can BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM Putting Your Hands To Better Use © 2009 Cathy Cohen, LMT LOW BACK & HIP UNIT MODULE 4 3 __________________________________________________________________ be felt to the bone. Draw the points you see but remember a trigger point could form at any segmental level. Because these are short muscles spanning between the vertebral bodies, trigger points could form anywhere along the centrally located motor endplate in each of the individual muscle fibers. During the hands-on workshop we learn a sequence to systematically release the points up the spine. I think you'll like it. You might even benefit from having work done on yourself as well. The whole weekend is spent creating length along the spine, lifting the front body and loosening the back region. I'm always very excited to teach the low back and hip unit because I know you can help so many people with this powerful knowledge of knowing how to assess, where to press and what to teach your clients. Have you ever wondered how a chiropractor or a doctor of osteopathy determines articular dysfunction without an X-ray? The two indicators of articular dysfunction are number one, and we are in the middle of page 27 of the study guide: tenderness over the spinous processes. So, when we're trying to determine which vertebral body is rotated, gently palpate over the spinous processes and if there's tenderness, that's a cardinal sign of subluxation and articular dysfunction. Number two is tenderness of the paravertebral muscles. If there’s increased tension on one side of the spine, it follows that the imbalance in the musculature would create a rotation in the vertebral bodies. I’m not prejudice, but bones are dumb and muscles are smart. A bone can’t just get up and walk out of alignment. So a chiropractor is basically using the same palpation methods we are when determining which vertebral segment to adjust. Dr. Lewitt, a researcher and practitioner, recognizes articular dysfunction as being closely related to increased tension caused by trigger points. Specifically he found a close association between trigger points and articular dysfunctions in the following four muscles: the iliopsoas, the thoracolumbar portion of the erector spinae, the quadratus lumborum and less frequently, the rectus abdominis. I know many of you work with chiropractors or have clients who are being treated with osseous manipulation. Think about if you're regularly treating these four muscles. Again, research shows BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM Putting Your Hands To Better Use © 2009 Cathy Cohen, LMT LOW BACK & HIP UNIT MODULE 4 4 __________________________________________________________________ a close association with articular dysfunction and increased tension due to trigger points in the iliopsoas, erector spinae, quadratus lumborum and rectus abdominis. Other differential diagnoses a physician may have ruled-out when a person presents with erector spinae trigger points are; and you will be so happy to see I've already typed the answers: fibromyalgia. I hope you listened to the introductory lecture at www.askcathyco- hen.com. The overlapping and perhaps artificial distinction between the pain caused from fibromyalgia and myofascial pain syndromes was presented. The next differential is: Radiculopathy caused from: • Ruptured disc • Spinal foramen encroachment • Tumor I had a gentleman who had a tumor in his spinal cord. The neurosur- geon actually missed it and referred him to me for muscle work. When I pressed around the tumor area there was such a strong discharge of energy that my hands were literally pushed away from the area. I had such a strong sense that something was wrong and it wasn't a muscu- lar problem. So after the first treatment I got on the horn and called my former boss, a neurologist friend who saw him within two weeks and correctly diagnosed the tumor in his spinal cord. I continued to see him for the palliative relief he received from massage. Before he died, you might appreciate this, he brought me two basil plants. He grew organic herbs along with being a health teacher at the local high school, a driver’s ed. instructor and the football coach. Shortly before his passing, he made a special trip out to my country office to bring me these plants. All winter, while every plant around it froze and died, this plant stayed green and lived another season. I don’t know how but I wanted to share that story with you. As healers, we occasionally ex- perience the mystery of the life death cycle, and if we are open to re- ceive it, receive a healing ourselves. Osteoarthritis is another disorder with similar pain patterns. Fat lob- ules, surface tears of a disc and spinal ligament strain are also listed as differential diagnoses in the text and the study guide along with renal disease and gallstones if it’s right sided. Again, we review differential diagnoses in this program, not because we diagnosis, but because it’s BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM Putting Your Hands To Better Use © 2009 Cathy Cohen, LMT LOW BACK & HIP UNIT MODULE 4 5 __________________________________________________________________ useful to know the diagnosis your clients may have been given for what might really be a myofascial pain syndrome.
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