Erector Spinae and Multifidus Static Manual Release

Differentiation

1. The erector spinae and multifidus are superficial muscles on either side of the spine.
2. With your patient in prone, ask them to adjust their clothing to reveal the lumbar region of their back. (With a little practice this technique may be performed through clothing.)
3. Identify the "valley" created at the spinous processes of the lumbar spine. The valley is created by the layers of fascia and skin being tightly bound together to the tips of the spinous process.
4. The "hills" or "columns" of tissue are created by the mass of the multifidus and erector spinae filling the fascial sheaths on either side of the spinous process like long, tube-shaped balloons.
5. The fibers of the multifidus and erector spinae course in opposite directions with different attachments.
   • Erector Spinae
6. The fibers of the erector spinae course vertically with some obliquity from infromedial to superolateral from their attachments on the sacrum and spinous process out toward the transverse processes and angle of the ribs.
7. Position your hips so they are adjacent to the patient's hip or thigh, facing the patient's opposite shoulder. This will put you in position to strum perpendicular to the fiber direction.
8. Using a thumb over thumb hand position, press into the paraspinal mass and slide your hands from lateral to medial with a slight obliquity from inferolateral to superomedial.
9. You should be able to identify thick fascicles coursing in the obliquity described above.
   • Multifidus
10. The multifidus originates on the spinous process and courses down toward the transverse processes 2 - 3 segments below.
11. Position your hips so they are adjacent to the patient's shoulder, facing the patient's opposite hip. This will put you in a position to strum perpendicular to the fiber direction.
12. Using a thumb over thumb hand position, press into the paraspinal mass and slide your hands from lateral to medial with a slight obliquity from superolateral to inferomedial.
13. Attempt to "strum" the more "flat" fascicles of the multifidus
    • Note: The majority of the mass and trigger points of the multifidus are adjacent to the mid and lower lumbar spine and course toward the posterior superior iliac spine (PSIS). The mass and trigger points of the erector spinae can be found adjacent to the spine from the lower lumbar to the thoracic spine.

Potentially Sensitive Tissues

• Providing excessive force is not used on patients with acute/irritable pain, and the practitioner is reasonably careful with where they apply pressure, it is unlikely that any sensitive structures are at risk during this technique. The transverse processes and rib cage do a pretty good job protecting the more sensitive structures; for example; nerve roots, ganglia, kidneys, etc.

Trigger Points

• Because the erector spinae and multifidus are segmentally innervated, trigger points may occur in any fascicle along their length.
• A very common multifidus trigger point occurs adjacent to the L4/L5 segment, just medial the PSIS.
• Common erector spinae trigger points seem to develop adjacent to the mid-lumbar spine and thoracolumbar junction, perhaps where these fascicles originate on the thoracolumbar fascia.

Release Technique

• Erector Spinae
  1. This technique is most comfortable with the patient lying in prone and the practitioner standing on the affected side.
  2. Position your hips so they are adjacent to the patient's hip or thigh, facing the patient's opposite shoulder.
  3. Using a thumb over thumb hand position, press into the paraspinal mass from lateral to medial with a slight obliquity from inferolateral to superomedial; perpendicular to the fiber direction of the erector spinae .
  4. Attempt to identify any taut bands that seem abnormally dense or resistant to compression.
  5. Once a taut band is located, the length of the band is explored for a dense nodule and consistent pressure is applied. Generally, "bowing" the fibers with some lateral to medal force will aid in "pinning" the nodule.
  6. Consistent pressure is held until the nodule softens under the practitioner's fingers, or tissue density/sensitivity is significantly reduced (generally 30 - 120 seconds).
• Multifidus
  1. This technique is most comfortable with the patient lying in prone and the practitioner standing on the affected side.
  2. Position your hips so they are adjacent to the patient's shoulder, facing the patient's opposite hip.
  3. Using a thumb over thumb hand position, press into the paraspinal mass from lateral to medial with a slight obliquity from superolateral to inferomedial; perpendicular to the fiber direction of the multifidus .
  4. Attempt to identify any taut bands that seem abnormally dense or resistant to compression.
  5. Once a taut band is located, the length of the band is explored for a dense nodule and consistent pressure is applied. Generally, "bowing" the fibers with some lateral to medal force will aid in "pinning" the nodule; however, the fibers between the PSIS and spinous process of L4, L5, and S1 respond well to posterior to anterior pressure.
  6. Consistent pressure is held until the nodule softens under the practitioner's fingers, or tissue density/sensitivity is significantly reduced (generally 30 - 120 seconds).