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