This is Brent of the Brookbush Institute, and in this video we're bringing
you another manual technique. Now if you're watching this video I'm assuming
you're watching it for educational purposes, and that you are a licensed
manual therapist following the laws regarding scope of practice in your
state or region. That means athletic trainers, chiropractors, physical
therapists, osteopaths, licensed massage therapists you are likely in the clear
to do these techniques. Personal trainers this probably does not fall within your
scope of practice, although you might be able to use the palpation portion of
this video to aid in learning your functional anatomy in an educational
setting, supervised by a licensed manual therapist. Now before we place our hands
on a patient or client it is important that we assess and have a good rationale
for doing so, and of course if we're going to assess then we should be
reassessing to ensure that the manual technique we're using is effective, and
we have a good rationale for continuing to use that technique. In this video were
going to go over static manual release of the erector spinae muscle. I'm going
to have my friend Melissa come out, she's going to help me demonstrate. We're going
to use the same palpate and compress technique we've been using for all of
our static manual release videos, using that that four-step process of
differentiating, knowing where our common trigger points are, knowing what not to
press on, and of course getting our patient inclined in good position and us
in good position so that we have good technique. Starting with a
differentiation of tissues your erector spinae are fairly superficial, and
providing we're not talking about trying to differentiate the various erector
spinae muscles, they're actually not that hard to palpate. The three muscles
combined create a column of tissue on either side of the spine. I think you
guys instinctually knew this right. this this valley is created by the skin and
underlying fascia being tacked down to the spinous process, and then the
thoracolumbar fascia and fascia along the spine here, all the way
into like our cervical thoracic fascia create these columns wrapping around the
erector spinae muscles that create hills on either side for our palpation. The
only thing we have to consider outside of knowing where these hills are, is what
direction of a diagonal these fibers go in, because we're going to want to go
back to that stroke perpendicularly to find the densest fascicles, and then go
parallel along the dense fiber to find the nodule hyperactive point,
trigger point. Alright so here's how the diagonals work. most of the erector
spinae, in fact all of the erector spinae have a diagonal that goes from lumbar
spine essentially to shoulder. If you think in that direction from inferior
medial to superior lateral, and then you just drew parallel lines in your head,
that's the direction of the erector spinae. The only muscles that are a
little different being erectors of the spine that can
also develop trigger points is our multifidi, our trigger points for our
multifidi are usually in our lumbar spine here is what we're talking about, and
they go in the other direction. They go from inferior lateral to superior medial.
If I'm going to palpate tissues that run this way again so we're back to a erector
spinae, I'm going to set up my hips so they're even with Melissa's hips and
then my hands are going to be going in the direction of Melissa's head, and that
would be my perpendicular stroke. So that's not too bad. When I do my erector
spinae I'm facing this way, and then I can just survey the length of my erector
spinae. I'm just kind of picking up my hand,
strumming over the tissues. Now it helps to know where your trigger points are.
Your two common trigger points that we're usually releasing in the erector
spinae are right in the middle of the lumbar spine, like in line with somewhere
between l2 and l4, and then just above the thoracolumbar junction there tends
to be another trigger point. So if I know that I might go right to those points
first just to see if I can narrow this this search down a little
bit, and when I find really dense fascicles again, I'm then going to go in
line with a fiber, search the whole fiber here for a nodule and acute point of
density and acute point of overactivity, And then you guys can use one of your
various comfortable hand grips either thumb over thumb just again leaning in,
you can use the technique I like to use as you guys know which is kind of
having that dummy thumb underneath, or putting my pisiform hamate over my thumb,
or putting my thumb in my thenar groove here. So in this case what I'm
going to do is pisiform hamate, and I'm just going to hold 30 seconds to two minutes
to kind of pin down the tissue. Notice I am I'm not pushing straight
down, I'm kind of pushing this way, that does help to keep me from playing that
game of like put your finger on top of a marble just and it just like keeps
shooting out this way. I tend to not only push down but push a little bit so
that I'm kind of like bowing this tissue this way, which holds that trigger point
underneath my thumb. Now if I want to switch around and do the multifidus,
maybe I have done all of my erector spinae,
I'm then going to put my hips level with Melissa's shoulders, and I'm now facing
her opposite hip. I can then go through, and guys these are going to be
lumbar spine right, otherwise as we get up in the thoracic spine the multifidus
are not well developed in the thoracic spine, and of course when we we do the neck that's a
whole different set of techniques which we talked about in different video. So if
we're doing multifidus it is going to be lumbar spine. We're going to go this way,
this direction, a little closer to our spinous process until we find an acute
point of overactivity or density. It does help to kind of bring the pants down a
little bit, so that you don't have to feel through another
layer of clothing right. You already have the skin to feel through, you already
have some adipose tissue fascia, there's a lot going on back here that we
got to feel through to just feel these small increases in tissue density. And in
fact, the common trigger point here is actually somewhere between, in that
little divot between our PSIS and then the spinous process of l4 l5. Like right
in here there's like a very common trigger point, all right so if I push in
there, how does that feel Melissa? Yeah a little a little tender. This is
definitely a common trigger point. As far as is there anything in this area that
maybe we shouldn't put our hands on, well no if providing that we're staying close
to the vertebral column, our transverse processes for the most part protect us
from being able to do damage to things that would be deeper and more sensitive.
It would be pretty hard for example for me to push down so hard that I damaged a
nerve or damaged an internal organ. Like you'd have to be way out here to
get to some of your internal organs, and I know people worry about that, but the
transverse processes protect us pretty well. Of course if somebody was or had
acute lumbar pathology like a nerve root adhesion that was kind of new. Or they
were experiencing some pretty significant sciatic symptoms, or you had
like a lumbar herniation, obviously be careful. Don't go in and push
down as hard as you possibly can. It's not so much that this is one of those
things that you need to watch where you put your hands, but maybe how you put
your hands. If I knew somebody was very sensitive to posterior to anterior
pressure I might even bring the table up a little
higher, so that I can get a little bit more of a horizontal pressure
so that I'm not getting so much of this. We can still pin tissues pretty good by
pushing them towards the spinous process. how does that feel Melissa? It's still very tender, of
course she has no lumbar pathology that we need to worry about, but you guys can
kind of imagine how this would be helpful. Back to client position,
notice when I wanted a more horizontal direction I raised the table, when I want
a more vertical direction of course I'm going to lower the table. What you don't
want to do and this is just if you think about it some common sense, you don't
want a high table and trying to be pushing down,
we don't want arms like this. We want arms straight. We want to use our fingers
maybe to palpate just because we need that sensitivity, but then when we
palpated the tissue that we need and we're just applying pressure, we
really want to apply pressure not with hand strength and arm strength, but just
by weaning our body and using body weight. I'm actually not using any
strength at all here. My elbows are just shy of lock, my arms are nice and
straight, and I push down, I can tell you guys this is where having mirrors in
your office comes in handy. I know not everybody has that, but if you have
mirrors in your office check your own posture every once in a while. I know we
put mirrors and offices for assessments of our patients, but I think sometimes we
need as much assessment on our technique and posture while we work. Alright so
just a real quick recap guys, common trigger points just above the
thoracolumbar junction right in the middle of the lumbar spine, and then in
that little soft area between the PSIS and spinous process of l4 l5 usually a
multifidus trigger point, Eerector spinae perpendicular strokes are this way,
because those fibers run this way multifidus run this way, so we set up
this way. Stay tuned for a close-up recap. You guys
can see the trigger points I've marked out, here are the most common trigger
points in the erector spinae and the multifidus. One just above the
thoracolumbar junction the other right in the middle of the lumbar spine, and
then of course that multifidus trigger point often occurs right between the
PSIS and the spinous process of l4 l5 and that soft tissue divot there. Now if
we're going to palpate and release the erector spinae, because they had a
inferior medial to superior lateral diagonal, I want to line my hips up with
Melissa's hips, and then my hands are kind of going in the direction towards
her opposite shoulder. I'm going to do my perpendicular strokes, strumming these
fibers just like guitar strings, looking for the densest or tensest guitar
strings. Once I find the densest tissues, I then go along the length of that
tissue to see if there's any sort of nodule or acute point of hyperactivity, a
trigger point, once I find that point then I can go -the palpating thumb
becomes my dummy thumb, and I can just place either my thenar groove
over that thumb, or my pisiform hamate over that thumb. Straighten out my arms,
lean in, apply pressure for thirty seconds to two minutes. Once I get a
release there, then maybe I keep palpating, keep strumming all these
fibers looking for any other shorter points. You have to remember that your
erector spinae is made up of tons of fascicles
right that all run in parallel this way. So it is possible to have multiple
trigger points in multiple different levels these are simply the most common
trigger points. Now for the multifidus remember that instead of going this way,
since the multifidus go superior medial to inferior lateral, I have to go this way,
that I have to turn myself around, so now my hips are in line with Melissa's
shoulders, my hands going towards her opposite
hip, and it's a little different palpation, it's a little different feel than these
big erector spinae muscles. The multifidus are usually a little flatter. But
you're going to look for the densest fascicles. Once you find them, once again we'll go along that
fascicle to find any tender nodule, and then once I find it, I can either do my
thumb over thumb, pisiform hamate over thumb, or a my I can even do thenar
groove over thumb like this, holding for 30 seconds to two minutes, until I get a
release. So there you have it, knowing your functional Anatomy will definitely
help your manual technique. It'll help you differentiate structures so that you
can place your hands where they need to be, as well as make you aware of these
sensitive structures around the tissue that you're trying to target. Things like
nerves and lymph nodes, and arteries. Make sure that if you're going to place your
hands on a patient that you have done an assessment and have a good rationale for
placing your hands on that patient, and if you're going to assess make sure you
reassess to ensure that your technique was effective, and you have a good
rationale for using that technique again. Now with manual therapy, one on one live
education is incredibly important, please be looking for opportunities like
workshops and mentorships, and maybe even classes at your local university, that
can get you some one-on-one individual instruction or at least some live
classroom instruction, so you've had a chance to be critiqued and mentored by
somebody senior to you with some experience in manual therapy techniques.
And before you bring this stuff back to your rehab, fitness or performance
setting, please practice on colleagues. There is no substitute for practice and
it is going to take a while to get accustomed to some of the techniques
that we show in these manual technique videos, don't expect to learn them in two
or three, or even five minutes. You want to have hours of experience under your
belt, working on various different body sizes and shapes, so
that when you do get that first paying client, first paying customer then you're
really trying to make a good positive impact, really trying to promote better
outcomes, you feel comfortable with that technique. I look forward to hearing
about your outcomes and hearing your questions in the comments section of
this video. I'll talk with you soon.
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