Indications for treatment

Special notes

Quadratus lumborum (QL) forms a quadrilateral-shaped muscle that extends from the iliac crest to the 12th rib as well as additional sets of fibers running from both the 12th rib and iliac crest to the transverse processes of most of the lumbar vertebrae. It has a free lateral border, which is usually palpable when placed under light tension (see sidelying position, p. 361). A sheet of thoracolumbar fascia lies both anterior and posterior to QL, thereby wrapping it in a fascial casing. These fascial extensions merge laterally and attach to the transverse abdominis, thereby providing a tensional element of support for the lumbar region.

The QL is often reasonably grouped with the psoas muscles as a deep lateral muscle of the trunk, providing a portion of the deep abdominal wall. However, it has been placed in this text with the muscles of the lumbar region so that it is addressed while the patient is in a prone position. Additionally, its direct action on the lumbar vertebrae is unquestioned, as is its ability to deform lumbar discs. (The psoas muscle is discussed with the deep abdomen on p. 287.)

While QL’s most obvious task is that of lateral flexion of the trunk and lumbar spine, its less obvious roles include elevation of the hip (especially important during gait), extension of the lumbar spine when contracting bilaterally, (possibly) to provide flexion of the spine or perhaps to stabilize it during contralateral flexion (Travell & Simons 1992), to (possibly) offer assistance in normal inhalation (stabilizing diaphragm’s rib attachment) as well as forced exhalation (coughing, sneezing), and to assist in unilateral trunk rotation on a fixed pelvis.

As mentioned earlier in this chapter, Norris (2000a) has described the divided roles in which quadratus is involved.

The quadratus lumborum has been shown to be significant as a stabilizor (sic) in lumbar spine movements (McGill et al 1996) while tightening has also been described (Janda 1983). It seems likely that the muscle may act functionally differently in its medial and lateral portions, with the medial portion being more active as a stabilizor (sic) of the lumbar spine, and the lateral more active as a mobilizer (sic). (See stabilizer/mobilizer discussion in Box 2.2, and in Volume 1, Chapter 2).

Janda (1983) observes that when the patient is sidebending, ‘when the lumbar spine appears straight, with compensatory motion occurring only from the thoracolumbar region upwards, tightness of quadratus lumborum may be suspected’. This ‘whole lumbar spine’ involvement differs from a segmental restriction, which would probably involve only a part of the lumbar spine.

Quadratus fibers merge with the diaphragm (as do those of psoas), which makes involvement in respiratory dysfunction a possibility, both via this merging and its attachment to the 12th rib. It plays a role in forced exhalation (such as coughing) and during speech and singing, by fixing a base for controlled relaxation of the diaphragm (Gray’s anatomy 2005). It also stabilizes the rib, and therefore the diaphragm, during inhalation.

The lumbodorsal junction (LDJ) is biomechanically important because it is the only transitional juncture where these two mobile structures meet. Dysfunction may result from alteration of the quality of motion between these structures (upper and lower trunk/dorsal and lumbar spines). In dysfunction, there is often a degree of spasm or tightness in the muscles that stabilize the region, notably psoas and erector spinae of the thoracolumbar region, as well as quadratus lumborum and rectus abdominis.

Symptomatic differential diagnosis of muscle involvement at the LDJ is possible, as follows.

There is seldom pain at the site of the lesion in LDJ dysfunction. Lewit (1985) points out that even if a number of the associated muscles are implicated it is seldom necessary, using PIR methods [MET], to treat them all since, as the muscles most involved (discovered by tests for shortness, overactivity, sensitivity and direct palpation) are stretched and normalized, others will also begin to normalize ‘automatically’.

Trigger points in QL may be activated by persistent structural inadequacies (such as lower leg length differential or developmental anomalies of the lumbar spine), overload (especially from an awkward, twisting position), trauma including auto accidents, postural strain during leisure (see Chapter 4) or sport (see Chapter 5) or work activities, or even while putting clothes on the lower body (socks, pants, pantyhose, etc.), walking on slanted surfaces or when straining during gardening, housework or other repetitive tasks (Travell & Simons 1992).

Travell & Simons (1992) provide an extensive list for differential diagnosis and a more extensive discussion than that which is offered in the following summation. These listed conditions should be ruled out in patients with associated symptoms but the reader is also reminded to examine the patient for trigger points in quadratus lumborum and associated tissues, when there exists a diagnosis of one (or more) of these conditions. Even though a diagnosis of a listed condition may be accurate and other pathological or dysfunctional conditions may exist, trigger points may be a readily remediable secondary perpetuating factor. Consideration should also be given to the possibility that a trigger point’s referral pattern may be the entire source of a painful condition that is ‘masquerading’ as the diagnosed condition. It is essential, however, not to disregard the possibility of organ or structural pathology mimicking QL dysfunction, which may have the potential to progress to an irreversible degree if neglected. Conditions that should be ruled out when confronted with apparent QL dysfunction include (Travell & Simons 1992):

Functional assessment for shortness of QL

NMT for quadratus lumborum

• The patient lies in a prone position and the practitioner stands at the level of the hip on the side to be treated. A light amount of lubrication is applied to the skin over the QL fibers. Only a portion of QL lies lateral to the erector spinae; however, the gliding strokes described here will influence tissues that are superficial to and lateral to QL, which may also influence QL’s ability to relax.

• Gliding strokes are applied with both thumbs, from the crest of the ilium to the 12th rib, while remaining immediately lateral to the erector spinae (Fig. 10.32). The gliding process is repeated 4–5 times on this first section of tissue. The practitioner should avoid undue stress on her thumbs by pointing the tips of the thumbs toward the direction of the glide rather than placing the tips toward each other during the stroke, which can strain the thumb joints. (See correct hand positioning in Chapter 9, p. 197, Box 9.7)

Figure 10.32 Although only a small portion of quadratus lumborum is palpable, this gliding stroke can be valuable in assessing as well as producing lengthening of surrounding tissues in addition to QL.

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• The thumbs are then moved laterally onto the next section of tissue and the gliding process is repeated 4–5 times. A third strip of tissue is usually available before encountering the fibers of external oblique. These gliding strokes can also be applied to the external oblique, if needed.

• Gentle friction can be used to examine the attachments of QL on the ‘floating’ 12th rib, which varies in length. Excessive pressure should be avoided, especially in patients with known or suspected osteoporosis, and the potentially sharp end of the rib should be carefully palpated.

• With the fingers of the cephalad hand wrapping around the rib cage and the thumb pointed toward the spine at a 45° angle (Fig. 10.33), the thumb is slid medially on the inferior surface of the 12th rib until it is just lateral to the erector spinae. Special care is taken to avoid pressing on the sharp lateral edge of the 12th rib or the lateral ends of the transverse processes. Static pressure or mild friction is applied to the transverse process of L1 to assess for tenderness or referred pain patterns.

Figure 10.33 Care must be taken to avoid pressing on the sharp lateral edge of the 12th rib or the lateral ends of the transverse processes while palpating near or on them.

• The treating thumb is then moved inferiorly at approximately 1-inch intervals and the palpation step is repeated to search for L2–4. The transverse processes are not always palpable and are usually more palpable at the level of L2 and L3. If rotoscoliosis of the lumbar spine exists, the transverse processes are usually more palpable on the side to which the spine is rotated.

• The practitioner now turns to face the patient’s feet while standing at the level of the mid-chest. Caudally oriented repetitive gliding strokes are applied to the most medial section of the quadratus lumborum, from the 12th rib to the iliac crest, while remaining lateral to the erector spinae. These gliding strokes are applied in sections in the same manner as the cranially oriented strokes were applied previously and can also be continued onto the oblique fibers, which lie lateral to QL.

• While continuing to face the patient’s feet, the practitioner applies transverse friction to the attachment of QL on the uppermost edge of the iliac crest while assessing for tender attachments and taut or fibrotic fibers. This frictional assessment can be continued through the oblique fibers as well.

Additional NMT applications to quadratus lumborum may involve the patient in a sidelying position with the treatment of muscles attaching to the pelvis (See p. 280).

MET for quadratus lumborum 2 (Fig. 10.34)

Figure 10.34 MET treatment of quadratus lumborum. Note that it is important after the isometric contraction (sustained raised/abducted leg) that the muscle be eased into stretch, avoiding any defensive or protective resistance which sudden movement might produce. For this reason, body weight – rather than arm strength – should be used to apply traction

(reproduced with permission from Chaitow (1996)).

• The practitioner stands behind the sidelying patient, at waist level.

• The patient has the uppermost arm extended over the head to firmly grasp the top end of the table and, on an inhalation, abducts the uppermost leg until the practitioner palpates strong quadratus activity (abduction to around 30°, usually).

• The patient holds the leg isometrically contracted, allowing gravity to provide resistance, for 10 seconds.

• The patient then allows the leg to hang slightly behind himself, over the back of the table.

• The practitioner straddles this suspended leg and, cradling the pelvis with both hands (fingers interlocked over crest of pelvis), transfers weight backward to take out all slack and to ‘ease the pelvis away from the lower ribs’, as the patient exhales.

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• The stretch should be held for not less than 10, and ideally up to 30, seconds.

• The method will be more successful if the patient is grasping the top edge of the table, so providing a fixed point from which the practitioner can induce stretch.

• The contraction followed by stretch is repeated once or twice more with raised leg in front of and once or twice with raised leg behind the trunk, in order to activate different fibers.

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• The direction of stretch should also be varied so that it is always in the same direction as the long axis of the abducted leg. This clearly calls for the practitioner changing position from the back to the front of the table, as appropriate.

Variation 1 (Fig. 10.35)

Figure 10.35 Prone PRT treatment of quadratus lumborum

(adapted from Deig (2001)).

While the practitioner maintains the monitoring contact on the tender point, the patient is asked to externally rotate, abduct and flex the ipsilateral hip to a position that reduces the ‘score’ significantly. The limb, flexed at hip and knee, should lie supported on the treatment table. The patient turns his head ipsilaterally and slides his ipsilateral hand beneath the flexed thigh, easing the hand very slowly toward the foot of the treatment table until a further reduction in the pain score is noted. This combination of hip flexion/abduction/rotation and arm movement effectively laterally flexes the lumbar spine, so slackening quadratus fibers. If further reduction is required in the pain score (i.e. it is not already at ‘3’ or less), the practitioner’s caudad hand should apply gentle cephalad pressure from the ipsilateral ischial tuberosity. This final compressive force usually reduces the score to ‘0’. This position should be held for at least 30 and, ideally, up to 90 seconds before a slow return to the starting position.

Variation 2

Practitioner is standing on the same side of the table as the QL being treated. With the cephalad hand applying monitoring pressure to the tender point, the practitioner’s caudad hand grasps the patient’s ipsilateral thigh, just proximal to the knee, and eases it into slight extension until there is a reduction in reported sensitivity. The patient’s thigh may then be supported by the practitioner’s caudad thigh as she rests her knee on the table. The practitioner then gradually abducts the leg until the pain is reported to reduce by at least 70%. Fine-tuning may involve slight internal or external rotation of the thigh (whichever eases the pain most) and a final degree of compression should be added (if it effects a pain reduction) by easing the thigh in a cephalad direction. This final position should be held for between 30 (if compression is added) and 90 seconds, before a slow return to the starting position.

Superficial paraspinal muscles (lateral tract) (see Fig. 10.25c and Volume 1, Fig. 14.14)

Attachments: Iliocostalis lumborum extends from the iliac crest, sacrum, thoracolumbar fascia and the spinous processes of T11-L5 to attach to the inferior borders of the angles of the lower 6–9 ribs

Antagonists: To lateral flexion of lumbar region: contralateral fibers of oblique abdominal muscles, rectus abdominis, quadratus lumborum

Indications for treatment:

Special notes

William Kuchera (1997a) describes the erector spinae as one of the four major muscles (along with latissimus dorsi, gluteus maximus and biceps femoris) involved in stabilizing the sacroiliac joint by means of inducing force closure. He also highlights the need to maintain a sense of the interconnectedness of spinal and general bodily biomechanics and of the role of the erector spinae in this.

The first three lumbar vertebrae serve as primary posterior attachments for the crura of the abdominal diaphragm. These vertebrae also supply attachments for the erector spinae mass of muscles that extend from the pelvis all the way to the neck and head. The latissimus dorsi muscle connects the pelvis with the upper extremity. Through the lumbar aponeurosis and fascia, the lumbar region is functionally attached to the hamstrings, the gluteal muscles, and the iliotibial band into the lower extremity; through the oblique abdominal muscles, the posterior lumbar region is functionally related to the anterior abdominal wall.

Everything connects to everything and much can be gained by keeping this constantly in mind.

Vleeming et al (2007) describe the erector spinae as being:

This means that during the process of nutation (see Chapter 11), the erector spinae ensure that the cephalad aspect of the SIJ is compressed, while the caudal aspect widens.

• If the erector spinae are weak this will lead to (and may result from) what Vleeming et al (2007) term ‘insufficient nutation’; that is, there would be a reduced ability for the sacral base to move anteriorly between the ilia.

• If, additionally, gluteus maximus is weak, with implications for reduced sacrotuberous ligament activity and therefore inadequate sacroiliac compression (‘self-locking’), a chain reaction of negative influences involving the thoracolumbar fascia ensues, possibly also involving latissimus dorsi.

• This pattern of dysfunction is likely to result in increased compensating tension in biceps femoris, ultimately rotating the pelvis posteriorly (so engineering counternutation at the SI joint) and flattening the lumbar spine.

• This in turn may lead to an unstable low back.

• An exercise that encourages a stable lordosis, including a strengthened erector spinae, is suggested. See Fig. 10.40 below, and its accompanying text description, for rehabilitation exercise for weak erector spinae.

Figure 10.40 A suggested exercise with lordosis of the lumbar spine and nutation of the SIJ. The biceps femoris, gluteus maximus and erector spinae are simultaneously activated

(reproduced with permission from Vleeming et al (2007)).

Snijders et al (1997) have shown that the slightly stooped (reduced lordosis) posture adopted by many low back pain patients results in reduced psoas activity and an unloading of the SI joint, so easing discomfort. This posture may, however, increase load on possibly painful structures, such as the long dorsal SI ligaments, via increased activity from the erector spinae muscles. Interestingly, the wearing (by the low back pain patient) of a small rucksack (backpack) weighing approximately 6 lbs/3 kg, diminishes erector spinae activity, while still allowing the pain-reducing slight stoop to be maintained. Reduction in low back pain in males with back problems as well as females, peripartum, have been noted using these tactics, according to Snijders et al (1997).

Norris (2000b) discusses the flexion relaxation response, which occurs with flexion of the spine during a lifting effort. When the spine is in almost full flexion (during lifting), the erector spinae become electrically ‘silent’, as an elastic recoil occurs involving the posterior ligaments and musculature. ‘During the final stages of flexion, and from 2° to 10° of extension, movement occurs by recoil of the stretched tissues rather than by active muscle work’. However, in a case of chronic low back pain, if the erector spinae are in spasm, the flexion relaxation response is likely to be obliterated.

Braggins (2000) reports on a very significant perspective on the possible etiology of sudden low back pain/dysfunction that occurs on bending to lift a light object.

Cholewicki [1997] and McGill [1998] found that stability of the lumbar spine diminished during periods of low muscular activity, making it vulnerable to injury in the presence of sudden unexpected loading. The spine will buckle if the activity of lumbar multifidus [see p. 270] and the erector spinae is zero, even when the forces in large muscles are substantial… for example a person could work all day on a demanding job and then ‘put his back out’ stooping to pick up a pencil from the floor in the evening. Buckling behavior can be limited to a single level from inappropriate activation of muscles.

It is obvious from the current knowledge of trigger point activity that such entities in the erector spinae could be part of a scenario that induced single-level (or more widespread) muscular weakness or inappropriate activation. (See discussion on trigger points in the Essential Information section of this volume, and in Volume 1, Chapter 6. See also Box 10.4 for discussion on lifting.)

Trigger points located in these vertical muscular columns refer caudally and cranially across the thorax and lumbar regions, into the gluteal region and anteriorly into the chest and abdomen (see Volume 1, Fig. 14.16).

The erector spinae system is discussed in Volume 1, Chapter 14, due to its substantial attachments in the thoracic region where its numerous attachments onto the ribs require that it be released before intercostals are examined. When the intercostal muscles are examined as described in that chapter, the practitioner may encounter tender attachment sites that appear to lie in the erectors. Marking each tender spot with a skin-marking pencil may reveal vertical or horizontal patterns of tenderness. Clinical experience suggests that horizontal patterns often represent intercostal involvement, as these structures are segmentally innervated, while vertically oriented patterns of tenderness usually relate to the erector spinae muscles.

Vertical lines of tension imposed by the erector system can dysfunctionally distort the torso and contribute significantly to scoliotic patterns, especially when unilaterally hypertonic. Leg length differential, whether functional or structural, may need attention in order to sustain any long-term improvement in the myofascial tissue brought about by treatment or exercise.

The posterior fascial lines (of potential tension), which run from above the brow (over the head and down the back) to the soles of the feet, are a critical line of reference to altered biomechanics of the spine and thorax (see fascial chains, Volume 1, Chapter 1). There may be widespread effects on postural adaptation mechanisms following any substantial release, for example, of the middle portion (erector group) of that posterior line. If the lamina myofascial tissues are also released, the tensegrity tower (the spine) could potentially adapt and rebalance more effectively. However, the practitioner should note that following such a series of releases, a requirement for structural adaptations will have been imposed on the body as a whole, as the arms move to new positions of balance and the body’s center of gravity is altered. The patient’s homecare use of stretching, applied to the neck, shoulder girdle, lower back, pelvis and legs, coupled with postural exercises should be designed to facilitate and stabilize the induced adaptational changes.

While release of excessive tension might appear to be always desirable, it is important to consider the demands for compensation imposed by induced soft tissue release. Local tissues, and the individual as a whole, will be obliged to adapt biomechanically, neurologically, proprioceptively and possibly emotionally. Engineering any substantial release of postural muscles, before other areas of the body (and the body as a whole) are prepared, may overload compensatory adaptation potentials, possibly creating new areas of pain, structural distress or myofascial dysfunction (‘The part you treated is better, but now I hurt here and here’). Other osseous and myofascial elements may already be adapting to preexisting stresses and may become dysfunctional under such an increased load.

However, if treatment has been carefully planned and executed, the process of adaptation to a new situation, following local soft tissue treatment, while almost inevitably producing symptoms of stiffness and discomfort, should be recognized as a probable indication of desirable change and not necessarily ‘bad’. The patient should, therefore, be forewarned to anticipate such symptoms for a day or two following NMT or other appropriate soft tissue manipulation.

Erector spinae inappropriate firing (prone extension) sequence test (see Volume 1, Fig. 5.5)

Erector spinae muscle shortness test 1 (Fig. 10.36)

Erector spinae muscle shortness test 2

Breathing wave: evaluation of spine’s response to breathing (see Volume 1, Fig. 14.7)

Preparation for NMT treatment

Having evaluated where a restricted area exists, MFR techniques can be applied to the tissues before any lubrication is used as MFR methods are most effectively employed when applied to dry skin. MFR calls for the application of a sustained gentle pressure, usually in line with the fiber direction of the tissues being treated, which engages the elastic component of the elastico-collagenous complex, stretching this until it commences to and then (eventually) ceases to release (this can take several minutes). A more complete description is presented on p. 204.

Functional technique In situations where the erector spinae are particularly sensitive, functional positional release technique may be applied to provide an opportunity for reduction in hypertonicity and sensitivity prior to NMT application (see Fig. 10.7 and also notes on functional methodology in chapter 9, p. 203). Alternatively, functional methods may be used following NMT to further ease sensitive tissues.

MET variation using slow isotonic eccentric stretching

Isotonic eccentric contraction/stretches have attracted various labels. If performed rapidly there is a degree of (controlled) tissue damage and the descriptor used is of an ‘isolytic’ contraction. Such strategies are rarely (but effectively) used in treatment, for example, of chronic TFL shortness, where the objective is to stretch the tissues forcefully and to then encourage remodeling by means of patient-applied stretching as homework (Chaitow 2006).

Slowly applied isotonic eccentric contraction/stretches have been named SEIS (slow eccentric isotonic stretch) (Chaitow 2010) as well as ‘eccentric MET’ (Liebenson 2001). The method involves the patient engaging a restriction barrier and then attempting to maintain that barrier position (using between 40% and 80% of available strength) while the practitioner slowly overcomes this resistance and lengthens the contracting muscle, so achieving an eccentric contraction.

The purpose of this technique is to facilitate (tone) the muscles being slowly isotonically stretched and at the same time to reciprocally inhibit the antagonistic muscles, without producing significant degrees of tissue damage such as would occur in a rapid isotonic eccentric stretch. The indication for this approach is when there is a need to release tension in individual or multiple muscles (ideally hypertonic postural muscles), while simultaneously toning their weakened/inhibited antagonists.

Ruddy’s ‘pulsed’ MET and the erector spinae muscles

Osteopathic physician TJ Ruddy developed a method that utilized a series of rapid pulsating contractions against resistance, which he termed ‘rapid resistive duction’. Ruddy’s method (now known as ‘pulsed MET’) called for a series of muscle contractions against resistance, at a rhythm a little faster than the pulse rate. This approach can be applied in all areas where isometric contractions are suitable. Its simplest use involves the dysfunctional tissues (or joint) being held at their resistance barrier, at which time the patient, against the resistance of the practitioner, is asked to introduce a series of rapid (2 per second), minute efforts toward the barrier. The barest initiation of effort is called for with, to use Ruddy’s term, ‘no wobble and no bounce’.

Anterior tender points/flexion strains

Strains in the lumbar region, including those involving the erector spinae, which occur in flexion, reflect as areas of tenderness in the muscles that are shortened, acutely or chronically, in relation to the dysfunction. These are usually found on the anterior trunk, i.e. for the lumbar area these tender points are mainly located in the abdominal musculature.

Positional release methods for treating flexion dysfunction of the lumbar region are described on p. 286 with the abdominal muscles.

Rehabilitation exercise for weak erector spinae (Fig. 10.40)

Vleeming et al (2007) describe a simple exercise that will effectively encourage nutation at the sacroiliac joint as well as toning gluteus maximus, the hamstrings and the erector spinae, while simultaneously encouraging a lengthening of shortened hamstrings.

Additional rehabilitation exercises are presented in Chapter 7 with other self-help techniques.

Multifidi

Attachments: From the superficial aponeurosis of the longissimus muscle, the dorsal surface of the sacrum and the mamillary processes of the lumbar vertebrae, these muscles cross 2–4 vertebrae and attach to the spinous processes of the appropriate higher vertebrae

Innervation: Dorsal rami of spinal nerves

Muscle type: Postural (type 1), shortens when stressed

Function: When these contract unilaterally they produce ipsilateral flexion and contralateral rotation; bilaterally, they extend the spine. While multifidi can produce (primarily fine adjustment) vertebral movement, they serve more as ‘stabilizers rather than prime movers of the vertebral column as a whole’ (Simons et al 1999)

Synergists: For rotation: rotatores, ipsilateral internal oblique, contralateral external oblique

Antagonists: To rotation: matching contralateral fibers of multifidi as well as contralateral rotatores, ipsilateral external oblique, contralateral internal oblique

Indications for treatment

Indications for treatment

Special notes

Multifidi and rotatores muscles comprise the deepest layer of paraspinal muscles and are often thought to be responsible for fine control of the rotation of vertebrae. They exist throughout the entire length of the spinal column and the multifidi also broadly attach to the sacrum after becoming appreciably thicker in the lumbar region.

Bojadsen et al (2000) point to substantial differences between thoracic and lumbar multifidi fibers. They show thoracic multifidi to be deeper, thinner, and their fibers are more tendinous and oblique than multifidi fibers found in the lumbar spine. They suggest that these differences may have implications in their function.

Thoracic multifidi architecture suggests that it produces movements in a transverse plane (rotational) and that its tension and amplitude is lower than its thoracic counterparts.

Lumbar multifidi present as more vertical, consistent with movements in a sagittal plane, and is larger and longer. Additionally, multifidus fibers have significant vertical orientation at L5-S1 and T11-T12, where lumbar and thoracic spines (respectively) have the greatest degree of flexion and extension. Consistent with this concept, the most oblique fibers of multifidus are located at T1-T2, the joint segment with the greatest degree of axial rotation.

Bojadsen et al (2000) also note that multifidus fibers are the only muscle fibers posterior to the lumbosacral transitional point of L5-S1.

Kader et al (2000) found that 80% of low back pain patients examined had atrophy of lumbar multifidus muscle. They also determined that the correlation between multifidus atrophy and leg pain was significant, although radiculopathy symptoms, nerve root compression, herniated nucleus pulposus and number of degenerated discs were statistically not significant associated with the atrophy.

These muscles are often associated with vertebral segments that are difficult to stabilize and should be addressed throughout the spine when scoliosis is presented. Discomfort or pain provoked by pressure or tapping applied to the spinous processes of associated vertebrae, a test used to identify dysfunctional spinal articulations, may also indicate multifidi and rotatores involvement (Simons et al 1999).

Bogduk (2005) notes that some of the deepest fibers of multifidi attach to the zygapophysial joint capsules and appear to help ‘protect the joint capsule from being caught inside the joint during the movements executed by multifidus’. He also suggests that it is unlikely that multifidi actually produce rotation of vertebral segments. He postulates that they are more likely to act to stabilize the lumbar region against ‘the unwanted flexion unavoidably produced by the abdominal muscles’ during rotation of the thorax. Additionally, he suggests that the line of action of multifidus lies posterior to the lumbar curve, giving it a ‘bowstring’ effect that compresses the posterior portion of the discs. This allows it to ‘increase compressive and tensile loads on any vertebrae and intervertebral discs interposed between its attachments.’

Moore & Dalley (2010) suggest that the rotatores muscles lack sufficient strength and leverage to produce spinal movement, and may play a greater role in spinal proprioception, acting as a ‘kinesiological monitor’ (Fryer & Johnson 2005).

Trigger points in rotatores tend to produce localized referrals whereas the multifidi trigger points refer locally and to the gluteal, coccyx and hamstring regions. Cornwall et al (2006) suggest that multifidus also refers to the anterior and posteriolateral thigh, and possibly distally into the calf and medial ankle. These local (for both) and distant (for multifidi) patterns of referral continue to be expressed through the length of the spinal column. The lumbar multifidi may also refer to the anterior abdomen (see Volume 1, Fig. 14.18).

Indications for treatment

Special notes

The interspinales muscles are present only in the cervical and lumbar regions and sometimes the extreme ends of the thoracic segment. In the cervical region, they sometimes span two vertebrae (Gray’s anatomy 2005).

Though extension of the spine is usually noted as the primary function of these small muscles, Bogduk (2005) suggests that intertransversarii (and similarly these interspinales muscles) may act more as proprioceptive transducers as ‘their value lies not in the force they can exert, but in the muscle spindles they contain’. Consequently, they provide feedback that influences the behavior of the muscles which surround them. Bogduk (2005) notes, ‘Indeed all unisegmental muscles of the vertebral column have between two and six times the density of muscle spindles found in the longer polysegmental muscles, and there is a growing speculation that this underscores the proprioceptive function of all short, small muscles of the body.’

Indications for treatment

Restriction in lateral flexion

Special notes

These short, laterally placed muscles most likely act as postural muscles and stabilize the adjoining vertebrae during movement of the spinal column as a whole. The pattern of movement of intertransversarii is unknown, but thought to be lateral flexion, although Bogduk (2005) suggests they may act as proprioceptive transducers, monitoring movements to provide feedback, which will influence surrounding tissues.

These muscles are difficult to reach and attempts to palpate them may not be fruitful. Positional release and muscle energy techniques may prove useful in releasing these deeply placed tissues.

Causes of abdominal triggers

Soft tissue changes and triggers in the abdominal musculature are affected by very much the same factors that produce ‘stress’ anywhere else in the musculoskeletal system:

Scars from previous surgeries may be sites of formation of connective tissue trigger points (Simons et al 1999). After sufficient healing has taken place, an incision site can be examined by pinching, compressing and rolling the scar tissue between the thumb and finger to examine for evidence of trigger points. These tissues frequently respond well to repeated rolling and sustained compression, which can usually be repeated at home by the patient. Both authors have had substantial success in reducing scar tissue-referred pain in scars of recent origin as well as older scar tissue. Sufficient time (8–12 weeks) should be allowed for healing to take place prior to handling the scar tissue; however, lymphatic drainage can be applied immediately after surgery to the surgical site and surrounding tissues to assist in drainage.

Transverse abdominal scars, such as those usually created by caesarean section and hysterectomy, may impede lymphatic flow in the lower abdominal region, which, in this area, flows downward to the inguinal nodes. Properly applied lymph drainage techniques may reestablish lymph movement and, in some cases, can reroute the lymphatic flow around the scar tissues.

Differential assessment is obviously important in a region housing so many vital organs and attention to the overall pattern of symptom presentation is critical. The information discussed in this chapter regarding organ pathologies is intended to offer ‘red flags’ to the practitioner to proceed with caution or, in some cases, not to proceed at all until a clear diagnosis has been given. This information is not intended to be diagnostic itself, especially when diagnosis lies outside the scope of the practitioner’s license and/or training. When any doubt exists as to the primary origin of the condition (not to be confused with secondary symptom-producing evidence), expert diagnostic investigation is urged. This is true for all body regions but can be of crucial consideration in the abdominal region where underlying conditions can be life threatening.

Indications for treatment of all lateral abdominals

Special notes

The diagonally oriented oblique muscles are involved in trunk rotation, lateral flexion, stabilization of the pelvis (which supports the spinal column), and (along with transversus abdominis and rectus abdominis) compression of the abdominal viscera. Compression of the viscera affects positioning of the organs so as to oppose the diaphragm’s downward movement. When the diaphragm encounters the viscera and its central tendon is stabilized, the diaphragmatic attachments on the ribs pull the ribs into ‘bucket handle’ movement, thereby influencing lateral dimension of the thorax (which ultimately influences anterior/posterior dimension (‘pump handle’)) and significantly affecting respiratory mechanics (further discussion is found in Volume 1, Chapter 14).

When producing rotation of the trunk, the external oblique is synergistic with the contralateral internal oblique. However, when performing sideflexion, it is synergistic with the ipsilateral internal oblique (and antagonistic to the contralateral one). This unique situation well illustrates how a muscle can be both a synergist and an antagonist to another muscle.

The more horizontally oriented transversus abdominis constricts the abdominal contents, thereby contributing to respiration by positioning the viscera as well as preventing the subsequent anterior rotation of the pelvis (which abdominal distension would produce) with its numerous postural consequences. Its attachment into the thoracolumbar fascia gives it potential to provide support for the lumbar region, as explained on p. 259.

Karlson (1998) implicates external oblique and serratus anterior in rib stress fractures of elite rowers due to repetitive bending forces. Ziprin et al (1999) have reported entrapment of the iliohypogastric nerve due to defect in the external oblique aponeurosis, through which the nerve passes. Twenty of 23 athletes presenting with groin pain reported good to excellent results following surgical repair.

Trigger point patterns for lateral abdominal muscles are known to cross the mid-line into the contralateral side of the abdomen and to radiate up into the chest and to the contralateral abdomen and chest. They also refer into the groin and testicular region and into the viscera, as previously discussed, causing (among other conditions) chronic diarrhea (Simons et al 1999) (Figs 10.47–49).

Figures 10.47, 10.48, 10.49 Trigger point patterns of lateral abdominal muscles. These patterns may include referrals that affect viscera and provoke viscera-like symptoms, including heartburn, vomiting, belching, diarrhea and testicular pain

(adapted with permission from Simons et al (1999), Fig. 49.1 A-C).

Stretching and strengthening of the lateral abdominal muscles are indicated in many respiratory and postural dysfunctions as these muscles are often significantly involved. Lack of tone in these muscles may contribute to lower back problems, as has been discussed within this chapter. Rehabilitation and strengthening of these muscles are critical to spinal stability and details are offered in Chapter 7, as a self-applied abdominal muscle rehabilitation.

Indications for treatment

Indications for treatment

Pain at lower abdomen close to mid-line in the region of the muscle.

Special notes

The vertically oriented fibers of rectus abdominis primarily contribute to flexion of the thoracolumbar spine (possibly some lateral flexion) and assist in stabilizing the pelvis to avoid anterior tilt with its resultant significant postural consequences. The upper fibers can pull the upper body anterior to the coronal line and help sustain a forward head position. The lower fibers often show loss of tone and allow the pelvis to move into anterior tilt, thereby increasing lumbar lordosis and significantly influencing the spinal positioning in general.

Rectus abdominis is divided by 3–4 (sometimes more or less) tendinous inscriptions, which receive nerve supply from different levels. This allows each section to act independently and to influence each other. Considering how this anatomy applies to trigger point formation theories (see Volume 1, Chapter 6) one can readily see the great propensity for this muscle to form trigger points as each section lying between tendinous inscriptions may produce both central and attachment trigger points.

At the mid-line, the rectus sheaths merge to form the linea alba. Separation of the rectus muscles (common after pregnancy) is noted as a palpable groove at the mid-line, especially detectable when the person is asked to contract the muscles by performing a partial sit-up. Herniations of the linea alba may be palpable only when the patient is standing.

With rectus abdominis imbalance, the umbilicus can be seen to deviate toward the stronger (hyperactive) side and away from the weak, inhibited muscle, especially during various movement activities (laughing, coughing, leg lifting, etc.) (Simons et al 1999) and is usually apparent when the patient is asked to do a quarter sit-up with his arms crossed on his chest (Hoppenfeld 1976). This procedure is used to test the integrity of the spinal segment that innervates the rectus abdominis and the corresponding paraspinal muscles (which should also be assessed for weakness) and is considered a positive ‘Beevor’s sign’ when the umbilicus deviates to one side.

Transverse rectus abdominis musculocutaneous (TRAM) flap has been used for several decades in pelvic, vaginal, (Smith et al 2000) and breast reconstruction (Robbins 2005), and to reconstruct abdominal wall defects (Mathes & Bostwick 1977, Mathes et al 2000). Contributions from rectus abdominis occur in a variety of reconstructive surgeries in the head and neck, including defects of the orbit, the tongue, the cheek, the posterior mandible, and the neck (Kroll & Baldwin 1994). Lyos et al (1999) evaluated speech, articulation, and deglutition after replacement of the tongue in advanced carcinoma of the oral cavity (using rectus abdominis) to find that fifty percent of patients were able to eat pureed foods or better and sixty-four percent had acceptable speech.

Trigger point patterns for the anterior abdominal muscles are into posterior mid-thoracic, sacroiliac and lower back regions, into the lower quadrant of the abdomen (into McBurney’s point on right side, duplicating the pain of appendicitis), into the chest and into the abdomen, thereby creating many of the visceral patterns previously discussed, including dysmenorrhea, pseudocardiac pain and colic (Figs 10.53-55). Trigger points can be found in any abdominal muscle (Sharpstone & Colin-Jones 1994) and can mimic visceral disease or follow actual visceral conditions, producing pain that may last much longer than the initial event that set it off (Doggweiler-Wiygul 2004). The practitioner should not overlook this possibility; however, suspicion of visceral pathology takes precedence since delay can have serious consequences.

Figure 10.54 Trigger points in rectus abdominis can duplicate pain symptoms of appendicitis

(Adapted from Travell & Simons (1992)).

Figure 10.55 Painful or difficult menstruation (dysmenorrhea) may be due to rectus abdominis trigger points

(adapted from Simons et al (1999), Fig. 49.2 A-C).

Figure 10.53 Trigger points in rectus abdominis can refer posteriorly into the back

(adapted with permission from Travell & Simons (1992)).

Stretching and strengthening of the abdominal muscles are indicated in many respiratory and postural dysfunctions as these muscles are often significantly involved. Lack of tone in these muscles may contribute to lower back problems, as has been discussed within this chapter. Rehabilitation and strengthening of these muscles are important to spinal stability and details are offered in Chapter 7 of a self-applied abdominal muscle rehabilitation.

Local

The abdominal muscles are phasic (using Janda’s nomenclature – see Volume 1, Chapter 2) and therefore do not shorten as a whole when stressed, but rather display evidence of inhibition and lengthening. This contributes to instability in the spinal structures, as discussed earlier in this chapter. However, all abdominal muscles are capable of developing trigger points and areas of localized shortening, fibrosis, adhesions, etc., which may require normalization if contributing to pain or dysfunction.

If there is confusion as to why a ‘weakened’ or inhibited phasic muscle should require stretching, it may be useful to reread Volume 1, Chapter 2. The discussion in that chapter explains that all muscles have both postural and phasic fiber types and that it is the mix, the ratio, of type 1 and type 2 fibers, as well as the function of the muscle, that determines whether it is classified as phasic or postural, and so whether its tendency is toward weakness/lengthening or tightness/shortening when ‘stressed’. This means that a phasic muscle contains postural fibers, which are likely to shorten under adverse conditions (overuse, misuse, disuse, etc.), just as the phasic fibers in a postural muscle may weaken and lengthen under similar conditions.

When treating local dysfunctional changes, tactics might usefully include initial use of an isometric contraction followed by local stretching involving ‘C’ or ‘S’ bends, local myofascial release or other deactivating and lengthening techniques as presented in this text (such as those previously discussed for paraspinal use in the multifidi section).

Global abdominal MET

The use of SEIS involves the slow stretching of a muscle, or group of muscles, while they are contracting or are attempting to maintain a shortened, contracted state (see p. 266 for description of this isotonic eccentric method in treatment of the erector spinae).

This method effectively tones the inhibited antagonists to the short, tight, postural musculature. By slowly stretching the abdominal muscles while they are holding a flexed position, the abdominal muscles will be toned and the erector spinae released from excessive tone (Liebenson 2001). The mechanisms whereby strength and tone are restored to the abdominal muscles, following this type of procedure, involve a combination of active exercise (resisted isotonic contraction) and release of previously tight erector spinae musculature through reciprocal inhibition.

Indications for treatment of psoas muscles

Special notes

The bilateral psoas major bellies, subdivided into superficial and deep portions, descend the anterior aspect of the lumbar spine to join with the iliacus muscle as they both (surrounded by iliac fascia) course through the lacuna musculorum (deep to the inguinal ligament) to attach to the lesser trochanter of the femur. Two bursae, the iliopectineal bursa and the iliac subtendinous bursa, lie between the muscle (or its tendon) and the underlying bony surfaces.

The psoas major may also communicate with:

The sometimes present (50–60% according to Travell & Simons (1992) and Gray’s (2005)) psoas minor courses anterior to the major and ends at the pubic ridge with attachments also spanning to the iliac fascia. Since it does not cross the hip joint (and therefore cannot act upon it), it likely provides weak trunk flexion (Gray’s anatomy 2005), extension of the lordotic curve and elevation of the ipsilateral pelvis anteriorly (Travell & Simons 1992).

At the lumbar attachments of psoas major, the medial deep fascia of the muscle forms tendinous arches on the lateral side of the vertebral bodies and through these arches course the lumbar arteries, veins and filaments from the sympathetic trunk (Gray’s anatomy 2005). The lumbar plexus courses between the two layers of the psoas major and is vulnerable to neural entrapment; whether this is produced by taut bands of trigger points has yet to be established (Travell & Simons 1992).

Controversy exists as to the extent of various functions of the psoas major but all sources agree that it (along with iliacus) is a powerful flexor of the hip joint. EMG studies suggest that it laterally rotates the thigh, does not participate in medial rotation of the thigh, flexes the trunk forward against resistance (as in coming to a sitting position from a recumbent one) and that it is active in balancing the trunk while sitting (Gray’s anatomy 2005).

Psoas major is the most important of all postural muscles (Basmajian 1974). If it is hypertonic and the abdominals are weak, exercise is often prescribed to tone these weak abdominals, such as curl-ups with the dorsum of the foot stabilized. This can have a disastrously negative effect, far from toning the abdominals, as increased tone of the already hypertonic psoas may result, due to the sequence created by the dorsum of the foot being used as a point of support. When this occurs (dorsiflexion), the gait cycle is mimicked and there is a sequence of activation of tibialis anterior, rectus femoris and psoas. If, on the other hand, the feet could be plantarflexed during curl-up exercises, then the opposite chain is activated (triceps surae, hamstrings and gluteals), inhibiting psoas and allowing toning of the abdominals. Additionally, full sit-ups activate the psoas when T12 leaves the ground. Curl-ups or pelvic tilts are better designed for abdominal toning, with diagonal movements added to assist in toning the lateral abdominal wall, without placing undue stress on psoas.

The psoas major behaves in many ways as if it were an internal organ (Lewit 1985). Tension in the psoas may be secondary to kidney disease and may reproduce the pain of gall bladder disease (often after the organ has been removed). It has been noted that the psoas major communicates with fibers of the diaphragm as well as the posterior extremity of the plural sac above (Gray’s anatomy 2005) and Platzer (2004) notes that:

The fascia surrounds the psoas major as a tube, psoas fascia, stretching from the medial lumbocostal arch to the thigh. Thus, any inflammatory processes in the thoracic region can extend within the fascial tube to appear as wandering abscesses as far down as the thigh.

Psoas fibers merge with (become ‘consolidated’ with) the diaphragm and it therefore influences respiratory function directly. Quadratus lumborum has a similar influence with the diaphragm.

Regarding spinal influences, Fryette (1954) maintains that the distortions produced in inflammation and/or spasms in the psoas are characteristic and cannot be produced by other dysfunction. He notes that when psoas spasm exists unilaterally, the patient is drawn forward and sidebent to the involved side with the ilium on that side rotating backwards on the sacrum and the thigh being everted. With bilateral psoas spasm, the patient is drawn forward, with the lumbar curve locked in flexion, thereby producing a characteristic reversed lumbar spine. The latter, if chronic, creates either a reversed lumbar curve if the erector spinae of the low back are weak or an increased lordosis if they are hypertonic.

Lewit (1985) notes: ‘Psoas spasm causes abdominal pain, flexion of the hip and typical antalgesic (stooped) posture. Problems in psoas can profoundly influence thoracolumbar stability’. Travell & Simons (1992) note that trigger points in iliopsoas refer strongly to the lower back and may extend to include the sacrum and proximal medial buttocks (Fig. 10.63). Additionally, it may refer into the upper anterior thigh (not illustrated).

Figure 10.63 Referral pattern for iliopsoas may continue further than illustrated into the sacrum and proximal medial buttocks. Additionally, it may refer into the upper anterior thigh (not illustrated)

(adapted from Travell & Simons (1992)).

In unilateral psoas spasms, a primary mechanical involvement is usually at the lumbodorsal junction, though a rotary stress is noted at the level of the 5th lumbar. Attention to the muscular components should be a primary focus, as attempts to treat the resulting pain, which is frequently located in the region of the 5th lumbar and sacroiliac, by attention to the osseous element will be of little use (Chaitow 2006) until the muscular tension is reduced.

Bogduk et al (1992) and Bogduk (2005) provide evidence that psoas plays only a small role in the action of the spine and that it ‘uses the lumbar spine as a base from which to act on the hip’. Bogduk also notes:

Psoas potentially exerts massive compression loads on the lower lumbar disc…upon maximum contraction, in an activity such as sit-ups, the two psoas muscles can be expected to exert a compression load on the L5-S1 disc equal to about 100 kg of weight.

Liebenson (Chaitow 2006) suggests that treatment aimed at relaxing a tight psoas and strengthening a weak gluteus maximus may be the ideal primary treatment for lumbo-sacral facet pain or paraspinal myofascial pain.

Some visual evidence exists in determining psoas involvement (Chaitow 2006).

CAUTION: Kuchera (1997b) reports that: ‘there are organic causes for psoas spasm that must be ruled out by history, examination and tests, including:

When treating, it is sometimes useful to assess changes in psoas length by periodic comparison of apparent arm length. The supine patient’s arms are extended above the head, palms together, so that the relationship of the fingertips to each other can be compared. A shortness will commonly be observed in the arm on the side of the shortened psoas. This ‘functional arm length differential’ usually normalizes after successful treatment. This method provides an indication only of changes in psoas length (or as confirmation of other findings, such as in the test below) rather than a definitive diagnosis itself since there may be other reasons for apparent differences in arm length.

Mitchell’s psoas strength test

Method 1 (working ipsilaterally)

• Patient is supine, knees flexed with feet resting flat on the treatment table. The practitioner stands on the side to be treated at the level of the abdomen.

• The finger tips of the practitioner’s hands (nails well trimmed) are placed vertically at the lateral edge of rectus abdominis approximately 2 inches lateral to the umbilicus (Fig. 10.66).

Figure 10.66 A slowly rotating circular movement of the hands allows a steady, safe penetration deeply into the abdomen where psoas resides.

• A steady, patient and painless pressure toward the spine is maintained with slight rotary movement of the fingers to insinuate the tips past any abdominal structures superficial to the anterior spine. If the aorta pulsation is strongly evident a slight deviation laterally should allow penetration of the finger tips until they sense contact with the psoas muscle (a fleshy or sometimes very hard, not intestinal, resistance).

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• Once this contact has been made the patient is asked to slowly increase flexion of the hip. The elbow of the practitioner’s caudad arm is placed against the flexing thigh to offer resistance, which will cause the psoas to contract firmly to confirm that the finger position is accurately placed. If the fingers lose contact with the muscle fibers, the circular rotating approach is repeated to help assure direct contact without intestinal entrapment (Fig. 10.67).

Figure 10.67 Once psoas has been located, muscle testing is applied by having the person actively flex the hip, which presses the knee against resistance applied by the practitioner’s elbow. The contraction of psoas should be distinctly felt by the practitioner’s finger tips to ensure correct hand placement.

• Once placement of the hands is confirmed to be directly on psoas, the practitioner uses her finger tips to apply a light direct compressive pressure onto the psoas. Fingers can be gently and slowly eased up or down the muscle (a couple of inches [2.5–5 cm] in each direction) as well as pulled laterally across the muscle, ever staying mindful of the organ structures previously noted. When tender areas or suspected trigger points are located, sustained pressure is applied for at least 8–12 seconds.

• Modifications can be made to the leg position by rotating the thigh medially (for the lateral aspect) and laterally (for the medial aspect). Additionally, the patient’s foot on the side being treated can be actively slid (by the patient) down the table slowly (returning the thigh to neutral position) to drag the psoas fibers under the compressing fingers for an active myofascial release.

• The iliopsoas tendon is accessible just inferior to the inguinal ligament when the fingers are immediately lateral to the femoral pulse. With the leg (knee bent) resting against the practitioner, the inguinal ligament is located as well as the femoral pulse. The practitioner’s first two fingers are placed between the femoral pulse and the sartorius muscle (Fig. 10.68). Static pressure is sustained or, if not too tender, gentle transverse friction is applied to the tendon of the psoas muscle, which may be exceptionally tender.

Figure 10.68 The iliopsoas tendon can be palpated between the femoral artery and the upper fibers of sartorius. Caution should be exercised regarding the femoral artery by locating its pulse and avoiding further palpation to the region of the artery. The tendon is the first myofascial tissue directly lateral to the femoral pulse.

Method 2 (working contralaterally)

An alternative approach is suggested for those whose knowledge of anatomy and pathophysiology is adequate to the recognition of the inherent risks involved in applying direct pressure, through the mid-line, toward the lumbar spinal attachments of psoas (Fig. 10.69).

Figure 10.69 Direct NMT treatment of psoas working through the linea alba

(adapted from Chaitow L (1988) Soft tissue manipulation. Healing Arts Press).

CAUTION: There is a very real risk attached to the application of pressure into the tissues of an aneurysm which may lie in the major blood vessels of this region and it is strongly suggested that this method only be used if there are no signs or symptoms of such a condition and if contact with all obviously pulsating structures is avoided.

Method 1

• The patient is prone with a pillow under the abdomen to reduce the lumbar curve.

• The practitioner stands on the contralateral side, with the caudad hand supporting the thigh.

• The cephalad hand is placed so that the heel of that hand is on the sacrum and applies pressure toward the floor to maintain pelvic stability. The fingers of that hand are placed so that the middle, ring and small fingers are on one side of L2–3 segment and the index finger on the other side (while the heel of the hand remains on the sacrum). This hand position allows these fingers to sense a forward (anteriorly directed) ‘tug’ of the vertebrae, when psoas is moved past its barrier.

• An alternative hand position is offered by Greenman (1996) who suggests that the stabilizing contact on the pelvis should apply pressure toward the table, on the ischial tuberosity, as thigh extension is introduced. The authors agree that this is a more comfortable contact than the sacrum. However, it does not allow access to palpation of the lumbar spine during the procedure (Fig. 10.70).

Figure 10.70 MET treatment of psoas in prone position with stabilizing contact on ischial tuberosity, as described by Greenman (1996)

(adapted from Chaitow (2001)).

• The practitioner eases the thigh (knee flexed) off the table surface and senses for ease of movement into extension of the hip. If there is a strong sense of resistance there should be an almost simultaneous awareness of the palpated vertebral segment moving anteriorly when this resistance is due to psoas.

• If psoas is normal, it should be possible to achieve approximately 10° of hip extension (without force) before that barrier is reached. Greenman (1996) suggests: ‘Normally the knee can be lifted 6 inches [15 cm] off the table. If less, tightness and shortness of psoas is present’.

• Having identified the barrier, the patient is asked to bring the thigh toward the table against resistance, using 15–25% of his maximal voluntary contraction potential, for 7–10 seconds.

• Following release of the effort (with appropriate breathing assistance, if warranted) the thigh is eased (if acute) to its new barrier or (if chronic) past that barrier and into patient-assisted stretch (‘Gently push your foot toward the ceiling’).

• In chronic situations where the stretch is introduced, this is held for at least 20 seconds and ideally up to 30 seconds.

• It is important that as stretch is introduced no hyper-extension of the lumbar spine occurs. Pressure from the heel of hand on the sacrum or ischial tuberosity can usually ensure that spinal stability is maintained.

• The process is then repeated on the same side before the other side is evaluated and treated if necessary.

Method 2 (Fig. 10.71)

Figure 10.71 MET treatment of psoas using Grieve’s method

(adapted from Chaitow (2001)).