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. However, osteopathic treatment, which mainly focuses on the functional capacity of the musculoskeletal system in the lumbar spine, has been shown to be clinically effective.

Lumbar spine

Bones

• See “lumbar vertebrae” in the article on the vertebral column.

Osteopathic landmarks

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

Hip drop test

• Function: assesses lumbar and thoracolumbar side bending
• Position: standing
• Procedure
  1. Stand behind patient and monitor iliac crests.
  2. Ask patient to bend one knee at a time without lifting the foot from the floor.
• Negative test
  • Lumbar spine side bends 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

Lasegue sign (straight leg raise test)

• See “Lasegue sign” in the article on degenerative disk disease.

Bragard sign

• See “Bragard sign” in the article on degenerative disk disease.

Lumbar dysfunctions

• Lumbar spinal segments can exhibit type 1 dysfunctions or type 2 dysfunctions.
  • See “Fryette's principles” in the article on general osteopathic principles for more information.
• Dysfunctions are diagnosed via static examination of individual segments.

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 component.
     • 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 (e.g., rolling your fingers up to check for flexion component causes the transverse processes to become more symmetrical → flexion dysfunction).
         • If a non-neutral component exists, a type 2 dysfunction is present.
       • If transverse processes on each side do not become more symmetrical with either movement, a type 1 dysfunction is most likely present.
         • A type 1 dysfunction can only be present if three or more adjacent segments are involved.

Type 1 lumbar neutral curve dysfunction

Muscle energy

• Position: lateral recumbent (posterior transverse processes pointing upward)
• Procedure
  1. Monitor curvature at apex.
  2. Flex hip until movement is felt at the apex.
  3. Lift feet upward until motion is felt at the apex.
  4. Ask 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.

High-velocity low-amplitude

• Position: lateral recumbent (posterior transverse processes pointing upward)
• Procedure
  1. Perform myofascial release.
  2. Monitor curvature at apex.
  3. Flex hip until movement is felt at the apex.
  4. Extend the inferior leg and hook the superior foot into the popliteal fossa.
  5. Rotate the upper torso upward.
  6. Place the superior arm in the axilla and the inferior arm on the iliac crest.
  7. Have patient take a deep breath.
  8. At the end of exhalation, apply a thrust on the iliac crest forward.
  9. Reassess.

Type 2 lumbar flexion dysfunction

Muscle energy

• Position: lateral recumbent (posterior transverse processes pointing down)
• Procedure
  • Monitor lumbar segment with posterior transverse process.
  • Flex legs until movement is felt at vertebral segment.
  • Ask patient to straighten and extend lower leg until motion is felt.
  • Switch monitoring finger.
  • Rotate top half of the patient into supine position.
  • Switch monitoring finger again.
  • Lift feet upward until motion is felt at the monitoring hand.
  • Ask 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

Facilitated positional release

• Position: prone
• Procedure
  1. Monitor lumbar segment with posterior transverse process and segment below.
  2. Flex knee off 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.

High-velocity low-amplitude

• Same as lumbar type 1 dysfunction

Type 2 lumbar extension dysfunction

Muscle energy

• 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 vertebral segment.
  3. Ask patient to rotate and hug table (Sims position).
  4. Lift feet off table and bring ankles downward.
  5. Ask 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

• Position: prone (posterior transverse processes pointing up)
• Procedure
  1. Place a pillow under the ipsilateral thigh.
  2. Monitor lumbar segment with posterior transverse process and 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

• Same as lumbar type 1 dysfunction