Lumbar osteopathy

Chronic lower back pain is one of the most common complaints in primary care medicine. Since the majority of these complaints cannot be attributed to a pathological cause, assessment in this region remains difficult. Osteopathic treatment, which mainly focuses on the functional capacity of the musculoskeletal system in the lumbar spine, may provide pain relief.

Lumbar spine

Bones

• The lumbar spine consists of five vertebrae (L1–L5).
• Have the largest vertebral bodies and quadrangular spinous processes
• The normal lumbar curve is lordotic.
• L5 articulates with the sacral promontory.
• See “Lumbar vertebrae” in the “Vertebral column.”

Ligaments

• Iliolumbar ligament
• Posterior longitudinal ligament

Musculature

• Erector spinae (iliocostalis, longissimus, and spinalis)
• Multifidus
• Rotatores muscle
• Quadratus lumborum
• Psoas
• Iliacus

Innervation

• The spinal cord terminates at approximately the level of L1.
• For more information, see “Nerves” in “Neurovasculature of the lower limbs."

Anatomical landmarks of the lumbar spine

• Level of the 12^th rib
• T10 dermatome: anterior to the L3 and L4 spinous processes
• Iliac crests: between L4 and L5 spinous processes
• Posterior superior iliac spine: level of S2

• General
  • The lumbar spine follows Fryette laws of spinal motion. See “Fryette laws” in “General osteopathic principles.”
  • Motions: flexion and extension (main motions), sidebending, and rotation
  • The greatest range of motion in the lumbar spine is flexion.
• Lumbosacral angle (Ferguson angle)
  • Refers to the intersection of a horizontal line that runs along the ASIS and an inclination line that runs along the PSIS and the angle of the sacrum.
  • Normal angle: 25°–35°
  • The lumbosacral angle affects the curvature of the lumbar spine, therefore modifications to this angle may lead to pain and somatic dysfunction.

In sacral torsions, L5 sidebends in the same direction as the sacral axis and L5 rotates in the opposite direction to the sacrum.

• Low back pain: see "Acute back pain"
• Musculoskeletal strain
• Neural tube defects: spina bifida
• Congenital spinal abnormalities
  • Lumbarization of S1
  • Sacralization of L5
• Neurological disorders
  • L5 radiculopathy, S1 radiculopathy
  • Cauda equina syndrome
  • Conus medullaris syndrome
• Degenerative disorders
  • Lumbar spinal stenosis
  • Spondylosis
  • Spondylolysis
  • Spondylolisthesis
  • Osteoarthritis
• Other conditions
  • Ankylosing spondylitis
  • Facet joint tropism
  • Referred pain (e.g., hip injury, psoas spasm)

Spondylolysis is diagnosed with oblique x-rays, while spondylolisthesis is diagnosed with lateral x-rays.

• Definition: : dysfunction or injury of the iliopsoas muscle that manifests with lower back pain that may radiate down the leg or to the groin
• Etiology
  • Overuse and/or trauma
  • Prolonged positions of hip flexion
  • Secondary to organic causes, e.g.,:
    • Appendicitis, sigmoid colon dysfunction
    • Endometriosis, salpingitis
    • Ureter calculi and/or dysfunction
    • Metastatic prostate carcinoma
• Pathophysiology: precipitating cause → hypertonicity or spasm of the psoas muscle → shortening of the muscle
• Signs and symptoms
  • Lower back pain, especially when changing positions from sitting to standing or walking
  • Radiation of pain (e.g., down the leg, into the groin, pelvis, sacrum, and/or lumbar vertebrae)
  • Difficulty maintaining an upright position
• Physical examination
  • Restricted hip extension, increased lumbar lordosis
  • Positive Thomas test
  • A tender point 1 cm medial to ASIS
  • Pelvic shift to the contralateral side (e.g., if the right psoas is affected, the pelvis will shift to the left)
  • Nonneutral dysfunction of L1 or L2
  • Contralateral piriformis spasm
• Diagnostics: mostly clinical diagnosis, based on history and physical examination
• Management
  • Osteopathic manipulative therapy
    • Counterstrain to the anterior iliopsoas tender point: flexion, side bending toward a tender point, and external rotation of the hip
    • Followed by HLVA or muscle energy directed toward the lumbar dysfunction
  • Physical therapy focuses on exercises that stretch and strengthen the psoas, spine, and hip
• Complications: chronically increased lumbar lordosis

The psoas muscle flexes the hips and externally rotates the lower limbs.

• Definition: a condition caused by inflammation or tearing of the iliolumbar ligament
• Etiology
  • Acute L5 disc protrusion
  • Spinal instability
  • Spondylolisthesis
• Clinical features
  • Tender point at the posterior iliac crest
  • Recurring, unilateral low back pain
  • Tight adductor muscle on the side of the dysfunction
  • Pelvic side shift toward the iliolumbar ligaments
  • Positive FABER test
• Management: counterstrain
• Complications: disk herniation

Lumbar spine diagnostics

• Lumbar spinal segments exhibit type 1 dysfunctions or type 2 dysfunctions.
  • Type 1 dysfunction (e.g., due to short-leg syndrome, scoliosis, unilateral tight psoas)
  • Type 2 dysfunction (e.g., due to a single-segment dysfunction)
• Dysfunctions are diagnosed via static examination of individual segments.
• Diagnosis must include all anatomical vertebral motions and be named according to their position of ease.

Static examination

• Position: prone
• Procedure
  1. Palpate each transverse process of the lumbar spine.
  2. Identify each posterior transverse process.
  3. Evaluate flexion or extension components.
     • On each segment with a posterior transverse process, roll your fingers up (to induce flexion) and down (to induce extension).
     • Transverse processes become more symmetrical when the spinal segment is placed into its freedom of motion : If a non-neutral component exists, a type 2 dysfunction is present.
     • Transverse processes on each side do not become more symmetrical with either movement: a type 1 dysfunction is present.

• Straight leg raise test
• Bragard sign
• Thomas test
• FABER test (Patrick test)
• For more information, see “Lasegue sign” and “Bragard sign” in “Degenerative disk disease” and “Hip joint examination” in "Orthopedic examination."

Hip drop test (osteopathy)

• Function: assesses thoracolumbar and lumbar sidebending
• Position: standing
• Procedure
  • Stand behind the patient and monitor iliac crests.
  • Ask the patient to bend one knee at a time without lifting the foot from the floor.
• Negative test
  • The lumbar spine sidebends toward the contralateral side.
  • Ipsilateral hip drops 20–25 degrees
• Positive test
  • Lack of smooth lateral convex curve of the lumbar spine toward the contralateral side
  • Ipsilateral hip drops <20 degrees

Muscle energy

Muscle energy for type 1 neutral curve dysfunction

• Position: lateral recumbent (posterior transverse processes pointing upward)
• Procedure
  1. Monitor curvature at the apex.
  2. Flex hip until movement is felt at the apex.
  3. Lift feet upward until motion is felt at the apex.
  4. Ask the patient to push feet downward against equal resistance for 3–5 seconds.
  5. Relax for 5 seconds.
  6. Re-engage barrier and repeat.
  7. Reassess.

Muscle energy for type 2 lumbar flexion dysfunction

• Position: lateral recumbent (posterior transverse processes pointing down)
• Procedure
  • Monitor lumbar segment with posterior transverse process.
  • Flex legs until movement is felt at the vertebral segment.
  • Ask the patient to straighten and extend the lower leg until motion is felt.
  • Switch monitoring finger.
  • Rotate the top half of the patient into a supine position.
  • Switch the monitoring finger again.
  • Lift feet upward until motion is felt at the monitoring hand.
  • Ask the patient to push feet downward against equal resistance for 3–5 seconds.
  • Relax for 5 seconds.
  • Re-engage barrier and repeat.
  • Reassess.

FDDR: Flexion dysfunction, patient pushes feet Down, posterior transverse process Down, lateral Recumbent position

Muscle energy type 2 lumbar extension dysfunction

• Position: lateral recumbent (posterior transverse processes pointing up)
• Procedure
  1. Monitor lumbar segment with posterior transverse process.
  2. Flex legs until movement is felt at the vertebral segment.
  3. Ask the patient to rotate and hug the table (Sims position).
  4. Lift feet off the table and bring ankles downward.
  5. Ask the patient to lift feet upward against equal resistance for 3–5 seconds.
  6. Relax for 5 seconds.
  7. Re-engage barrier and repeat.
  8. Reassess.

SUUE: Sims position, posterior transverse process Up, patient lifts feet Upward, Extension dysfunction

Facilitated positional release

Facilitated positional release for type 2 lumbar flexion dysfunction

• Position: prone
• Procedure
  1. Monitor the lumbar segment with the posterior transverse process and the segment below.
  2. Flex the knee off the table until motion is felt at the segment below the affected segment and adduct the hip.
  3. Internally rotate the hip until motion is felt at the monitoring finger.
  4. Optional: upward compression.
  5. Hold for 3–5 seconds.
  6. Reassess.

Facilitated positional release for type 2 lumbar extension dysfunction

• Position: prone (posterior transverse processes pointing up)
• Procedure
  1. Place a pillow under the ipsilateral thigh.
  2. Monitor the lumbar segment with the posterior transverse process and the segment below.
  3. Abduct (induces lumbar side bending) and internally rotate the hip.
  4. Apply an anterior force on the ankle (induces lumbar extension).
  5. Hold for 3–5 seconds.
  6. Reassess.

High-velocity low-amplitude (flexion or extension dysfunction)

High-velocity low-amplitude technique is the same for type 1 and type 2 dysfunctions.

• Position: lateral recumbent (posterior transverse process up)
• Procedure
  1. Apply myofascial release to the area being treated.
  2. Monitor motion at the dysfunctional lumbar segment.
  3. Flex the patient's legs until motion is felt at the monitored segment.
  4. Straighten the patient's inferior leg, and hook the foot of the superior leg in the popliteal fossa.
  5. Pull the patient's inferior arm away from the table in the caudad direction to introduce sidebending down to the level of the dysfunctional segment.
     1. For a lumbar segment sidebent right and rotated right, the patient will be in the left lateral recumbent position, thus pulling the patient's inferior (left) arm caudad will introduce sidebending to the left, as desired.
     2. For a lumbar segment sidebent left and rotated left, the patient will be in the right lateral recumbent position, thus pulling the patient's inferior (right) arm caudad will introduce sidebending to the right, as desired.
  6. Place one arm along the patient's torso (using the axilla as a point of leverage) and the other arm along the patient's pelvis (using the iliac crest as a point of leverage).
  7. Ask the patient to inhale deeply.
  8. At the end of exhalation, apply a thrust rotating the pelvis forward.
  9. Re-evaluate the dysfunctional segment.
• Position: lateral recumbent (posterior transverse process down)
• Procedure: Same as above, however, instead of pulling the patient's inferior arm in the caudad direction, the inferior arm is pulled cephalad.