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