0:04 This is Brent, President of the Brookbush 0:06 Institute, and in this video we're going 0:07 over a quadratus lumborum, or QL static 0:10 manual release. Now, if you're watching 0:11 this video, I assume that you're watching it 0:13 for educational purposes and that you are a 0:15 licensed manual therapist. That means 0:18 following the laws of scope of practice 0:20 in your state, you are allowed to do 0:22 manual release techniques- chiropractors, 0:24 athletic trainers, physical therapists, 0:26 massage therapists, osteopaths. I'm sure I'm 0:29 forgetting somebody, but nonetheless, you're 0:31 following your scope of practice. 0:32 Personal trainers, this video probably 0:34 does not apply to you, but you could 0:37 potentially do this with your peers or 0:39 any learning environment to help you 0:40 with your functional anatomy knowledge. 0:42 I'm going to have my friend, Sonja, come 0:44 out. She's going to help me demonstrate 0:47 this technique. Notice that she starts 0:49 face down so I can access her quadratus 0:52 lumborum. Before I would have Sonja even 0:54 begin to lie down so I could do this 0:56 technique, I would be 80% sure that her 0:59 quadratus lumborum is involved in this 1:02 technique. If I'm going to put my hands 1:04 on somebody, I want to know that her QL 1:07 is potentially causing things like an 1:10 asymmetrical weight shift, or maybe it's 1:13 related to something like some 1:15 sacroiliac joint pain, or maybe I've seen 1:18 some other dysfunction of her 1:20 lumbo-pelvic hip complex or lumbo-thoracic 1:22 spine that make me believe 1:25 putting my hands on her is warranted and 1:28 that quadratus lumborum release is going 1:30 to help her with whatever compensation 1:33 or patient complaint she's having. Now, 1:36 all of our manual release techniques 1:38 follow a very similar protocol that 1:40 basically comes down to palpate and 1:42 compress. But to get a little bit more 1:44 detail than that, we do need to know how 1:47 to palpate this muscle. We get bonus 1:49 points for knowing where the trigger 1:51 points are. I would start studying 1:53 trigger point maps. They definitely help 1:55 you with your hand placement and finding 1:57 those overactive tissues. We want to be 2:01 aware of anything around the tissue that 2:04 we're palpating that may be insulted or 2:07 irritated by pressure. In the case of the 2:09 quadratus lumborum, we do have to 2:10 consider that it is a deep muscle, and on 2:13 the other side of that is the viscera, 2:15 specifically the kidneys. 2:16 And last, we do have to think about 2:18 what is the best position for us to 2:22 actually palpate and release this muscle. 2:25 It's not just about patient comfort. Most 2:27 therapists I see are great about making 2:30 their patients comfortable. It is also 2:33 about your comfort, so make sure that you 2:35 are in a position- hopefully you have a 2:38 high-low table or have access to a table that 2:40 does adjust- so that you can use your 2:43 body weight and your leverage and not 2:45 just grip strength to actually get these 2:48 releases. We don't want anybody's career 2:50 ending early because their hands wore 2:52 out. So, to get to this muscle, I'm going 2:55 to have Sonja lift her shirt up 2:58 so that her belly's exposed 3:00 and her back's exposed. I'm just going to 3:03 go ahead and tuck this right up 3:05 underneath her sports bra here, so it 3:08 stays out of the way. Sonja, do you mind if I 3:10 move your pants here? So, what I'm going 3:12 to do with her waistband, guys, is I'm 3:14 just going to put it right up over- I'm 3:16 going to tuck it under- I'm going to 3:18 put it right up over her posterior iliac 3:21 spine. This is this is kind of 3:23 convenient for what I'm showing you guys 3:24 on film here, because I have her 12th rib 3:27 right here, and then I have her 3:29 posterior ilium, and right between that 3:31 is her quadratus lumborum. The only 3:34 thing we have to think about now is this 3:37 is a deep muscle. So, how do I 3:39 differentiate this muscle from all the 3:41 muscles that are on top of it, and also 3:43 make sure that I'm not going so deep I'm 3:45 just poking on her kidneys? I don't think 3:47 Sonja came in here to get her kidneys 3:48 poked on. 3:51 So, what I would suggest is if you put 3:54 the borders of your hands on the 12th 3:57 rib and the posterior ilium, you start 3:59 almost all the way on their side. Alright, 4:02 so we're, maybe, just a couple inches from the 4:04 most lateral border of their waistline, 4:07 and then you dig in just a little bit 4:12 and apply pressure toward their spine, so 4:15 lateral to medial here. Unlike your 4:19 transverse abdominis, external and 4:21 internal obliques that wrap all the way 4:23 around, your quadratus lumborum will have 4:26 a defined lateral border. I found it 4:30 right there, so now I got a nice lateral 4:32 border, and I can follow that border from 4:35 12th rib to posterior ilium, maybe just 4:38 for palpation skills purposes. But then 4:42 when I actually want to start looking 4:43 for trigger points and doing some 4:44 release, we do have a little problem in 4:47 our technique. You know we can't just do 4:50 those medial to lateral or lateral to 4:53 medial strums we've done on some of the 4:55 other muscles to find the tightest 4:58 fascicle. What you guys are going to have 4:59 to do is start at the lateral border, 5:01 pick up your fingers, and then move them 5:04 in a little bit, strum a few more fibers, 5:07 move them in a little bit, and strum a few 5:09 more fibers. So, I'm kind of like walking 5:12 my hands in towards her lumbar spine 5:18 rather than just these these broad 5:21 strums I did before. It's the same basic 5:23 concept. You're just going to find that 5:25 if you try to strum this deep, you're 5:27 going to get caught in tissue. I notice 5:31 there's a nice, tight fascicle there. Once 5:32 I find this nice, tight fascicle, 5:35 I'm going to move either cranially or 5:38 caudally, either towards her 5:39 head or towards her tail to see if I 5:44 can find if these tight fascicles are 5:47 associated with a tight nodule. If I 5:51 happen to find a tight nodule, just like 5:53 all of my other techniques, I'm going to 5:55 lean forward just until that point where 5:58 I get a little tissue resistance. 6:00 I always talk about 6:02 that exponential curve of tissue tension 6:04 and how we want to kind of be right in 6:05 the trough. I don't need to push as far 6:08 as her tissues will let me and find the 6:10 end of her tissue extensibility locally. 6:14 All I need to do is push just up to a 6:19 moderate amount of tension, maybe just 6:21 past the first resistance barrier. With a 6:23 little practice, you'll find you need 6:26 enough pressure to get a release, but apply too 6:28 much pressure and you'll get so much 6:30 feedback from the muscles, so much fight 6:32 from the muscle that you'll never get a 6:33 release. You want to be right in the 6:35 middle there. I'm going to hold for 30 to 6:38 120 seconds. Ideally, this table 6:42 would be a little higher. guys I have it 6:45 a little lower than I probably should- 6:46 for taping purposes. But if this was a 6:49 little higher and my arms were at 90 6:52 degrees, you'd see that all I have to do 6:54 is lean forward a little bit to exert 6:56 pressure. I don't need to man handle 7:00 her back. I don't have to use my arm 7:03 strength. We don't want to turn 7:04 this into a chest press. And then, once I 7:09 get a release, I can move on to my next 7:11 trigger point. Now, your trigger points 7:14 are really easy to find in your 7:16 quadratus lumborum. Your common trigger 7:18 points- and you'll see this in our 7:19 close-up recap- are right in the middle of 7:22 the length of the muscle and then there 7:24 tends to be some quadratus lumborum 7:25 trigger points right over the sacroiliac 7:29 joint, most often related to sacroiliac 7:31 joint pain. Alright, so after I did these, 7:34 I might come down here and do my same palpatory 7:37 techniques and find those tight tissues. 7:41 For these, you might have to be 7:44 at a little bit more of a lateral to 7:47 medial and posterior to anterior angle. 7:55 You're just going to hold until you get a release. Now we'll have the 7:57 close-up recap of our quadratus lumborum, 7:59 or QL release. You guys will notice I 8:02 have the trigger points already mapped 8:03 out here, but they're pretty easy to find 8:06 even if I didn't have them mapped out. 8:08 This one tends to be right in the middle 8:10 of the length of the quadratus lumborum. 8:12 This one tends to be right over the 8:14 sacroiliac joint and may be related to 8:17 sacroiliac joint dysfunction. So, when we 8:20 look for trigger points for the 8:22 quadratus lumborum, when we look for 8:24 those hypertonic fascicles, we are going 8:26 to go from lateral to medial rather than 8:29 posterior to anterior, as with the QL we 8:32 do have to consider what's around the QL. 8:34 The QL is a deep muscle and on the other 8:38 side of it is our viscera, specifically 8:41 our kidneys. I'm not really sure that I 8:43 want to be applying a lot of pressure to 8:46 the back of the kidneys, especially if 8:48 I'm going to do this over and over again 8:50 over several sessions, or if I'm going to 8:54 ask my patient to follow this up with a 8:56 home exercise program that includes QL 8:59 release. I'm not sure what that pressure 9:01 over time would do to my kidneys. I'm 9:03 going to go ahead and take my hands and 9:05 place the borders of my 9:09 hands kind of on her posterior 9:10 ilium and her 12th rib so I know where 9:13 I am. 9:13 And then, I'm going to use my thumbs to 9:16 kind of brush over, using my lateral to 9:19 medial strumming to find the tightest 9:20 fascicles, just like I have with all my 9:25 other muscles. I think with this muscle 9:27 you guys will notice that since it's deep to 9:29 things like my latissimus dorsi, my 9:31 transverse abdominis, and even to some of 9:33 the fibers of the internal obliques, 9:34 we're going to have to kind of pick up 9:36 our fingers here as opposed to being 9:38 able to do this type of strumming, which 9:40 we've done with other muscles. All I'm 9:42 going to do is strum more superficial 9:44 muscles if I do that. in this case, in 9:46 this particular instance, we're going to 9:48 want to find that lateral border of the 9:50 QL by going from lateral to medial, and 9:53 then picking up our fingers and slowly 9:58 going over those fascicles until we find 10:03 ones that feel abnormally dense, 10:08 abnormally tense. Once I find 10:12 them, then I can move 10:16 proximal to distal, or in this case 10:19 superior to inferior, inferior to 10:24 superior. I found a nice little 10:25 nodule right there. 10:27 So, to increase pressure, I'm just 10:29 going to- I have my elbows at about 90 10:32 degrees- I'm just going to lean 10:33 forward, applying pressure towards the 10:36 lumbar spine until I get that little 10:39 give back from the tissues. Remember, if 10:42 if tissue tension is mapped on a graph, 10:45 it kind of goes through an exponential 10:47 curve. I want to go right up to the point 10:50 where the tissue tension starts to 10:52 increase. I don't want to go beyond that. 10:54 We could say go just past the first 10:57 resistance barrier, but we don't need to go 10:59 to maximal tension in these tissues. If 11:03 you push too hard, you'll get so much 11:06 activity back that you'll probably never 11:09 get a release. I'm going to hold this for 11:11 30 to 120 seconds until I feel a release, 11:16 a reduction in tension, or my fingers start 11:21 to sink into the tissue a little easier. 11:23 These are all signs that you've gotten a 11:25 successful release. Once I have gotten a 11:28 successful release, I could 11:30 move on and see if I also have trigger 11:34 points just above the sacroiliac joint, 11:38 or I could move on to my next muscle. You 11:41 guys have it- a static manual release of 11:43 the quadratus lumborum, the QL, a great 11:46 technique to have in your bag of tricks. 11:49 This muscle does tend to follow the 11:51 activity of the erector spinae when it 11:55 comes to dysfunction and movement 11:57 impairment. It is one of those muscles 11:59 that can be problematic and can be a 12:02 source of increased tension, nociception, 12:06 and possibly pain, so you want to make 12:09 sure that as you're going through your 12:12 assessments for those with chronic low 12:13 back pain that the quadratus lumborum is 12:16 somewhere in the back of your head. Now, 12:18 as with all of these techniques, guys, 12:19 make sure you start with assessment 12:21 before you do any manual 12:22 technique. And before you do a manual 12:25 technique on a patient, you should 12:26 probably gather a colleague, grab one of 12:29 your mentors, especially if you can grab 12:32 another manual therapist and do some 12:35 practicing. Nothing takes the place of 12:38 live education when it comes to manual 12:40 techniques and/or the mentorship of a 12:43 manual therapist who can give you 12:45 feedback. Having something like a study 12:48 group or having a bunch of manual therapists 12:50 get together and practice these 12:51 techniques is education that I think 12:55 can't be replaced and, maybe, should be in 12:57 all of our repertoires. I look forward to 12:59 hearing how this particular technique 13:02 improved your outcomes. I'll talk with 13:04 you soon. 13:12
