Callison-LauHD02232022 Thumb

Quadratus Lumborum: Structure and Function and Treatment


Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hello, everyone. Thank you so much for coming to our discussion on the quadratus lumborum structure, function and treatment. My name is Matt Callison. I’m here with Brian Lau and we’re here to shortly discuss this. Amazing muscle that we use quite a bit in acupuncture. That’s also very popular in massage therapy, as well as functional medicine.

It’s a muscle that has been discussed for four decades as being a primary pain generator. But with the advancements within mile faster research and also with biomechanics and functional medicine, the quadratus lumborum is actually evolving into a muscle that is different than from when I first learned about it in sports medicine in 19, late 1986.

Early 1980s, actually. So it has evolved quite a bit with its actual functionality. So Brian and I here to be able to discuss a little bit about this muscle give some quick assessment and some quick treatment techniques with us. And Brian, is there anything that you want to go for as an overview before we jump right into

slide two now I think we can jump on in the presentation up.

Yep. All right.

All right. So the quadratus lumborum is a complex muscle with a various fiber directions. Okay, this is, what’s so interesting about this muscle is that it’s just not one pancake of a muscle. That’s going to elevate the ilium or lower the the 12th rib, which is the way that I was actually taught in the early 1980s, late 1980s is that it was an elevator of the ilium, which we’d really don’t see that very much at all anymore.

What we’ll be discussing is looking at these different fiber arrangements and how this muscle is seen more of a, like a cross-link between. At other muscles acting on the spine or the ileum. So it’s really quite interesting that its role as more of a, synergist or an assistant to a lot of other muscles in different movement patterns.

So we’re going to start to talk about that here in just a little bit. Let’s look and see where it is actually oriented. You can see that the muscles part of the post, your abdominal wall, looking at this cross section of as directly connected to the transverse of dominant. So Brian, can you get the cursor in there?

And maybe we can see that the quadratus lumborum has a direct line along that core line, right into the transverse of dominance. Now that’s via the lateral Rafa tissue. And because it’s got such a strong connection to the transverse abdominis, that is the quadratus lumborum. If there are dysfunctions or increased tensions or lack of.

Tension actually in the transverse of dominance in the Antar aspect, it will directly affect the quadratus lumborum and the poster aspect, and also vice versa. Common commonly you’ll see this with certain fascial distortions as well. Let’s get into the latter Rafa just a little bit more here and the next slide.

So let’s look at the quadratus lumborum and how it’s sandwiched between the anterior and middle layer of the thoracolumbar fat. As we know, the thoracolumbar fascia has three different layers. It has an anterior later layer. It has a middle layer and it has a

post to your person

noticing you’re actually doing a really dumb job plus, cause that’s not easy to do right now.

All right. So we’ve got the quadratus lumborum and the three layers of thoracolumbar fascia. Increased tension, lack of tension to the quadratus. Lumborum how it’s going to affect the transverse abdominis, how it’s also going to affect all layers of the thoracolumbar. So that poster layer, the thoracolumbar fascia is what we commonly see in the anatomy artwork or anatomy charts, where you can see on the backside, the white tissue, that’s connecting the store side down to the glute Maximus bilaterally.

So that would be your post to your thoracolumbar fascia. And we just need to remember that there are two other layers and the quadratus lumborum is sandwiched between those two layer. Very important. And let’s see what’s next.

All right. So looking now from an anterior view, you can see that post to your abdominal wall. You see the quadratus lumborum from there. And also the psoas. The psoas is something that Brian and I spoke about for, gosh, it was a three hour conversation on the structure, a tree, a function and treatment.

Which was great. It was a lot of fun because there were so many things to discuss on the psoas. And that was in January or was that Brian? He did that.

Yeah, we it was early, earlier in January, maybe mid January. I think it’s a loss of now recorded the week we had the live class still online live class in January 10th.

It sounds like. I think it seems about right.

That was the first of the acupuncture anatomy series that Brian and I. Intending to do quite a few videos. Within this realm or the folder of acupuncture anatomy. And this is the second one actually, but it’s coming up soon. So what this presentation today is actually going to be able to give you a couple of pearls that you can be able to really use with the quadratus lumborum and some knowledge about some possibly new knowledge about it.

And then if you wanted to actually go a little bit deeper with it, we’re going to talk for about two hours or just over two hours. I’m just the quadratus lumborum and it’s connection. And it’s connections. Like I was saying before the quieter, some borrowers is seeing more of a crossroad now, like an assistant or a synergist to a lot of other functional movements.

So it’s a lot of fun. It’s a lot of fun to be able to discover that and how it can actually be able to change a needle technique and also treatment protocols or extra points that you can be able to use in addition to the quadratus lumborum so not just local, but also adjacent and dystonia. So looking here at the view, you can see the quadratus lumborum there, that Brian has his cursor on I’m gracefully placed.

I might add. And where are the quadratus lumborum inserts? You can see how it has a direct connection to the diaphragm there at the RQ at ligament. So that would be the lateral arcuate ligament. Okay. Going over the, so ads would be your medial, Q it ligaments. So they act as like a sleeve where it is part of the function of the diaphragm, which is an important thing to remember when you are treating low back.

So then also take a look inferior where that quadratus lumborum attaches to the iliac crest. It interdigitates, it becomes as one with the Illy axis. And it’s really quite fascinating to see on a cadaver because the fibers do actually come together. So if we were to tease away the fibers underneath the iliacus and the quadratus lumborum with a scalpel, just riding along the periosteum, you could lift that up and it would just become one to.

And all the way to the diaphragm, if you continued up that way.

Yeah. True. True. All right. So Brian, I think, are you

taking it away now? Yep, I believe so. Okay. All right. So this is a from research with six cadaver specimens, really looking at the physical arrangement of the quadratus. Lumborum not keep in mind.

This is six specimens. So it’s not a hundred or 200 or 300 spins. But at least it gives a, it starts to give an idea of the complex arrangement of the quadratus lumborum. And when looking at these specimens in this research, there’s three layers to the quadratus. Lumborum, we’re looking at the back through the the, posterior part of the body right now.

So we’re looking at the posterior layer, but then there’d be a middle layer and there’d be an anterior layer. So there’s really three layers to this complex muscle of the quadriceps. And this particular research then compared the six specimens and looked at the various fascicle arrangement. And this is something we might expand upon when we do the the longer two hour class.

But just to give a quick overview of this now there’s first of all, there’s a lot of variability from specimen to specimen, variability, and size or place. Really number of assets, musicals all those types of things. But generally there was mostly at least half of the physicals acted on the 12th rib and there were Leo costal fast tickles.

So that’s what outlined in green from ilium to the 12th rib, there was Leo lumbar facet. That’s what in that more yellow line from the alien to the lumbar spine. Actually, there were some Elliot thoracic basketballs that went all the way up to the body of the 12th thoracic vertebra, but by and large, these are the bulk of the, vascular disease.

Leo costal, Emilia lumbar. The middle layer is the one that has the lumbo costal from the transverse processes to the 12th. You can’t see those from this image, but that would be sandwiched in that middle lane here. So do you have to memorize all of these different farcical arrangements? Not necessarily but, to understand the role or at least to understand the complexity of this muscle, it’s important to remember that there are these various layers, some going from alien to rib, some going from ilium to the lumbar spine, some going from lumbar spine to the 12th rib.

So very complex. And it’s a classical arrangement in size. And. So because of this complexity, the muscle fiber and physical orientation of the QL, it’s difficult really to identify the actions when you’re looking at the quadratus lumborum and this line of pulse the one thing, if it went from ilium to 12 three, that was just like a straight shot from the ilium to the 12th.

Speculate much more easily of what these this role would be because it would be acting from the hip to the rib. And it would be a little more of a straight shot, but because of the fact that there’s these various forces, various vectors acting on it, there’s a lot of uncertainty on the role, the action of the quadratus lumborum.

So let’s go over the general actions. Notice that all of these, at least the first two bullet points on the actions have an asterisk. So let’s talk about the asterick first. So these actions are really placed under question right now by researchers because of just what we said because of this complex arrangement.

So it seems that maybe the quadratus lumborum has not so much to do with a particular action. Let’s say lateral flection of the trunk Obliques are in a much better mechanical advantage to do lateral flection of the trunk, but the quadratus lumborum is there to help out with the, to assist with that, to be a helping aid at same time, it can stabilize the spine.

So there’s a lot of stabilization roles of it probably in potentially. And that’s what the research seems to show extension some sources say extension. It doesn’t really have a good leverage to do extension, but it has leveraged to help with extension help with directors. You can see a lot of different rotational aspects based on the fiber direction.

So really what it seems is that like, when Matt mentioned is really more of this cross link where it’s helping in assisting more functional units of, structures that are moving together. But the traditional roles of the quadratus lumborum is that there’s a unilateral contraction or when there’s a unilateral contraction that does lateral flection of the vertebral column of the lumbar spine.

And whereas the opposite side then would be stabilizing. So we were looking at this right QL that could laterally flex the the lumbar spine. So it’d be come. The lumbar spine would become concave to that side. Bilateral contraction is where it’s usually talked about as a extension, but it seems like it’s pretty minimal and extension and more about assisting if it doesn’t mean.

And then it does seem to have a role in assisting with inspiration because of it’s a poll on the 12th rib as the diaphragm contracts, it would want to lift the 12th rib. So the QL is under there to stabilize the 12th rib and, aid in countering the, diaphragm’s pole. So this would be important, but things like speech anything where you’re getting up there and really projecting your voice in particular, you can picture that QLD in there to assist with that.

So complex muscle.

Yeah. So those, oh, Hey Brian, can I add something to that? Sure, absolutely. So the first two bullets, you guys with those asterix. That research. They actually did some EMG studies on that and they had the patients go, or the models go into extension of the lumbar spine as well as lateral flection into a number of the D into the muscles that actually act on the spine.

And what they found was that the erector spinae was actually like 90% involved in the extension of the lumbar spine. Whereas the quadratus lumborum only 10%, which truly is very interesting. And they basically had the same results with the unilateral contraction. The quadratus lumborum as well. How is wasn’t really actually a primary mover.

It’s just, again, it’s like more of a cross-link across road, a synergist and assistant a stabilizer. So it’s really quite fascinating with that. And I think

we were discussing this recently about myself and I feel like working on the muscle, which is jumping ahead and I don’t want to get into too much on that now, but if the lumbar spine isn’t hyperextension.

To me. I’d never really think that I really want to lengthen the QL so much because it does have, it seems like it has a minimal role in extension, but to be able to get that free gliding of the QL and the erector speed and to be able to decompress the tissue. So you can almost try to lift the tissue out from, being buried deep into the lumbar spine.

To me, that’s how I think about it more. And its role of extension is more postural and less dynamic.

Yeah, the QL being more of a posture muscle, like for example, in single lady, single leg weight bearing in order to have the stability of the lumbar spine than the lateral sling comes into play. So you’ve got the glute medius and minimus and the tensor fascia Lata on one side, and then you’ve got the quadratus lumborum on the opposite.

With that sling, being able to keep the balance in the frontal plane when somebody is standing on one leg and how important that actually is, this is something that we’re going to discuss quite a bit further in the law. And discussion of the quadratus lumborum is coming up in a couple of months. It’s important gives you a lot of great treatment protocols and ideas about what senior channels to be able to treat locally, adjacent and distal as well as mild work and addition exercises to prescribe as well.

That’s going to be very important with that frontal plane. Cool boy, we talked about that slide for a long time.

Okay. A you’re on stuff. Yeah. The quadratus lumborum has a, relationship in terms of at least the topography of it with the lumbar plexus, but it’s really a little bit more complex than just that. So first of all, just a review of the lumbar plexus. This is coming from the ventral Rami of L one through L four, but if you look at this top image the subcostal nerve, the T 12 intercostal nerve, which is called the subcostal.

Share some fibers down into L one. So really the subcostal nerve five contributes to the lumbar plexus. Why are we focusing on the lumbar plexus, these specially, this upper portion, the subcostal nerve, the Elio hypogastric nerve which I don’t know. I can see this on the screen, but subcostal nerve would be right under that 12th rib.

Then the next one to come out would be the ilial hypogastric and then the ilioinguinal. Those travel right on that anterior surface of the quadratus. Lumborum okay. Interesting. But th those are also the primary innovation sources, which especially the subcostal nerve, which is map it’s going to get into in just a moment.

But something to bear in mind as we get a little farther in the lecturer, we’ll come back to this and talk about it is if we follow these these nerves that wrap around the posterior part of the abdominal wall and start to become anti. Because they have cutaneous sensory branches that create sensation that, that supplied the skin and then the sensory aspect for the posterior lateral gluteal region.

I think that says thigh, but that’s really say the gluteal region. Posterial lateral gluteal region. The greater trocanter region, the suprapubic region and the proximal medial thigh. So hold that thought, we’ll remind you about it. But just keep that in mind that, the nerves that are kind of part of the innovation of the quadratus lumborum that have us a structural relationship into, in terms of where they are have the sensory distributions to the lateral.

Greater trocanter grind and I’m up in the superpubic region. So we’ll come back and look at that and how that applies in just a bit. Anything you wanted to add to this map before jumping into the,

no, it was a good setup for what’s to come

fix some interest on it. All

right. So we’re staying within the motor nerve innervation. So this isn’t some research that I gathered. It’s really quite interesting. I found this to be true is that varying research articles and textbooks. There’s not agreement on which nerves actually innovate the quadratus lumborum, but the most important one will end up being the subcostal mainly with the research that’s below because of its large Dianne.

It’s measurement of being so large diameter, therefore you’re going to have more neurons and motor neurons it within that motor nerve, that’s going to be entering the quadratus lumborum and then it also discussed the ill hypogastric nerves that were also innervating the quadratus lumborum. But with those nerves, actually having less contribution to it.

So there are, what we know of is three primary. Motor entry points with the biggest one or the go-to one in my mind will be the one that the subcostal nerve is actually going to be intervening. So let’s go to the next slide because it does show some research on here and you can see, so here a you’ve got the T 11 intercostal nerve, and then you’ve got the subcostal nerve will be B.

You can see that it’s has a larger scale. And innovations to that. Now what they did is actually they opened up that subcostal nerve so that you can actually start to be able to see the different branches then see, is going to be your

So see what ended up being, I believe part of the hill in Greenville and possibly part of the ilial hypogastric so you can see how that subcostal nerve in B is going pretty close to. Brian, can you show on the far upper left corner that the iliac crest, the ilium there? Yeah. There you go. So you can see how that subcostal nerve is going toward the muscle valley of the quadratus lumborum.

So we’ll discuss the subcostal innervation coming up in the treatment section. All right, Brian.

All right. Some of the work we teach quite a bit and work with in the, sports medicine acupuncture program is the Sydney channels. So we’ve really been working for probably 10 years now coming up on 10 years now on really building a comprehensive model for the channel, send news DJing, gen 10 new channels, whatever translation you’re using for the.

And really highlighting the specific anatomical structures that are associated with each channel sinew, how they relate functionally to seeing things like their external internal relationships. In this case, the gallbladder send you a channel or other, correspondences to have they function together.

But for today, just looking straight at the myofascial plane that makes up the liver Sindu channel is quite interesting. Cause this one. A little diverges a little bit from the classical description. The classical description has the liver sinew channel terminating or ending at their groin at the genitals, I think specifically is what it says.

But if you look at the the myofascial plane and it has a much more interesting relationship in that, Line that’s coming up from the foot through the medial thigh, up through the ad doctors doctor longest brevis pectineus Priscilla’s adductor. Magnus is a different one. That’s more in the kidney sinew channel, but this more anterior line of the abductors longest brevis and tineas, that would be then very continuous with that fascial plane all the way up into the iliac.

And as Matt mentioned where the iliac has shares fascial fibers, interdigitates in with the quadratus lumborum. And then up into the tall throne, that would be the liver send you a channel. So if you follow that plane deep into the pelvic structure for the LA axis, it would come out into the QL.

And I know a lot of people might be thinking QL, it’s a back muscle. It seems like that would be urinary bladder maybe, or maybe even. Send you a channel, but if you think about it as being less of a back muscle, which it really isn’t, but more of an abdominal muscle it’s in the abdominal wall, it’s it’s much more of a yin much muscle, much more of a core stabilizing deep structure.

And it starts to make more sense, especially then when you look at that, continuous fascial plane through the abductor line, up into the iliac is QL and The would be a part of that also, especially the distal fibers. , it’s a little more complex than, we can get into today, but we covered this quite a bit in our so as a three hour class and different sort of relationships with the cell ads, but that this, the portion in particular would be part of deliver, send new channel also.

Yeah, Brian was sold me on this one was. Okay. When you gave me a call and you said, Hey, try this liver five points. And I, my practice on every person that day, I palpated their quieter to some warm and then needled liver five. And it was remarkable how well liver five, we will point at the liver channel, soften the quadratus lumborum on not couple, but every single.

And in particular, what we’ve been teaching this for Yon syndrome or the deep layer, which we’re going to actually be talking about just a little bit that y’all, don’t send him, but he was pretty magnificent to be able to feel how liver five and in combination of liver three. And I think I might be jumping ahead with information time.

Yeah, it is. It’s remarkable how well that does work. So I think we’re going into assessment now.

Yep. That is the case. So when I go ahead, no, go ahead.

Okay. So with elevated ilium, this is one thing that we can be able to look for, that we know that the quadratus lumborum, the myofilaments, the actin, and the mind.

Are going to be in a locked short position. It’s not because it’s pulling on the alien pulling upward, but it’s because the glute medius and the amendments have weakened on are allowing that ilium to actually rise up the opposite side. Glute medius and minimus are then shortened and pulling that side down the opposite side.

So it’s it’s the opportunity for this muscle then to become shortened. Now, commonly what we’ll see with this as well is a lateral tilt of the rib cage on the same side, which want to go to the next slide.

All right. So when you get that elevated ilium, what the body wants to do is to compensate. They start to lean to the same size, so it can start to balance itself. So that would be another sign that we can address. I’m looking from the post, your review, an elevated alium always go ahead and measure it with your fingers as well.

Just to confirm your visual findings and then look at the lateral tilt of the rib cage. Usually with the love handles, so to speak, you’ll see a difference between. And left sides and more of an accumulation of tissue when there’s an elevated ilium and a lateral tilt of the rib cage. So in that case, you’ve got the this 12th rib is now going to be actually coming down.

And which means shortening of pretty much all of the fibers of the quadratus from quadratus lumborum I would think making people. Tender to palpation and also Yon tender to palpation, as well as the motor entry point. Let’s go to the next slide. Brian, you want to chime

in on this? Yeah. And this particular image.

It looks like really more just lateral tilt without so much of a elevated ilium, a little tricky to tell. We’d have to almost get in there and get our fingers on. And make sure that what we’re seeing on the exterior surface matches, but just glancing at it. I don’t see a whole lot of elevation of the helium this particular person, but more about the lateral tilt more about that 12th rib being pulled, down.

So you don’t always have to see an elevated ilium with it, but frequently you’ll see these two go together, elevated ilium and lateral tilts with routine. This particular person is a massage therapist. So she leans a lot with her right arm in terms of using a pressure with her right arm quite a bit.

So you can see how that would have a propensity to shorten that right side.

Oh, do you want to say before we move on Matt, that these distal point recommendations are just go-tos that are frequently. Helpful for this condition. There’s ways we apply these in our program and really make determinations of which points to use, but you can just try them out and experiment with them in terms of the part of the full, comprehensive treatment.

In addition to the local points, which we’re going to be getting into, this is just a portion of the treatment, right? This isn’t like a whole treatment is treat the QL out the door. You go in the person. And it might temporarily help, but but you need to be much more comprehensive to get lasting results and, looking again at the fact that the QL across links.

So we need to treat multiple structures and look at his role of communicating between multiple, structures instead of just QL, maybe put a little electrical stem on it, out the door next patient comes in.

Yeah. Yeah. I forgot because we grabbed these slides from the senior channel class, which we have.

So the acupuncture distill those points we’re using as acupuncture is in assessment. We’ve discussed this a few times before, basically trying to be able to change an orthopedic exam and manual muscle test a certain particular posture by using different acupuncture points that will change that myofascial sin, U2.

Before and after and using acupuncture and assessment, it’s just basically seeing, can you make a change in that body using these acupuncture points? And once you can see it and retest it, then you pull those needles out. But you remember to be able to plug those needles back in during the comprehensive treatment of acupuncture, because you saw how it actually makes a difference.

And I think that’s where that’s where this is coming from. Good. I’m glad you explained

that Brian. Yeah. Maybe this is not a great time. I think there was some, a question on the QL and the diaphragm. I see some references to it, but I don’t see the actual question. So we’ll catch that at the end.

If if that hasn’t been answered already,

there it is. We do believe the QL Motorpoint help with help in effect with the diaphragm. Yeah, I would say that I, used the QL personally and I’ll see what Matt has to say. But personally, when I’m working with respiratory issues, I don’t even want to say respiratory issues cause that’s a broader category.

Restricted breathing when breathing seems like it’s a component of the back pain, maybe the person is more of a chest breather and that deep diaphragmatic breath is, and it isn’t filling the low back and massaging the, spinal joints and expanding. And that elastic aspect of the inhale, exhale, expanding the lumbar spine and expanding the soft tissue structures in that lower part.

I definitely go to QL as part of the treatment. It’s

absolutely also the, so as cause we teach we’d be able to see if the low back pain is actually could be. Weakening or an inhibited. So as it’s been constricted in the diaphragm, there’s a manual muscle test that you can use with that. Yeah, for sure.

So add also GB 20 stabbing, you’ll be 17 UV 23 for the kidneys. So as, and also quadratus lumborum I think would be a good idea.

I’ll say one other thing about it then maybe move on unless you have anything else to add. And Matt to it as is, I also think about what’s at the other side of the rib cage. So you have the QL attachment to the total.

And then you have the scalings attaching to the first two ribs. And I find that, especially with people who are more of these chest breathers, who are overusing the scalings is that relationship can be very important as it is speaking to scaling. Especially the anterior scaling is a little hard to needle unless you’ve had specific training on it, but at least some some myofascial work or some, softening manual work to help free some of that excess tension in the scalings.

And. Speaking to the tension at the QL, you’re working on both sides of the ribcage. That can be really useful.

All right, this is great. But how far should we go on this? We’ll start talking about forward head posture and

we got to get going. I can never get. All right. So yes, let’s now talk about needling. These points. And the upper left image, you can see pop patient, the extra point P guns. We know that P guns going to be located at 3.5, some lateral food lower court spot. The process of hell one. Really what I’m going for in this particular case is that the corner pocket I call it, it’s where the Elliot cost Alice also the quadratus.

Lumborum where they attach to that 12th rib. Just palpating along the 12th rib from the lateral aspect up into that corner, you can see a bit of a crease there. So the needle then would be inserted the same direction as my middle. And making sure that it’s not going to go anterior to the 12th rib. So it’s a really good idea to palpate that 12th rib and the topography of that all three, because you don’t want it to go and tear that could cause a pneumothorax.

So you don’t want to insert that and go Antar to the 12th rib caution is advised. Then you can look at the motor point, which is going to be approximately halfway between P gun and Yon. It’s not on every. The directions for finding this motor point, or it’s gonna be just lateral to you be 52 on some people you could find that just slightly more superior from the midpoint being between extra point Pentagon and Yon.

So that’s one aspect that you can get it, or you go slightly higher. If you get, if you can find you be 52, that’s going to put you in the ballpark of that subcostal innervation. So insert the needle, make sure it’s going to end up being parallel to the T. With the quadratus lumborum, I’m sure all of us have gone ahead and needle that quite a bit.

Being an educator and seeing a lot of people that are needing needling, the quadratus lumborum palpation is everything here, and you need to be able to make sure you are actually on that QL and on the deeper. I see a lot of students actually needling the ilial cost Dallas, which is going to get results.

Absolutely. But it’s not dealing the quadratus lumborum so it’s going to be different intent there. And we have in the upper right-hand corner, we have Jaan. This is going to be the deep layer of yang, which would be the quadri Islam. Attachment on that lateral aspect of the pelvis. And it’s amazing how far the lab, the quadratus lumborum actually attaches to the pelvis.

So this particular needle technique is, not going to be on the edge of it, but it is going to be going through the quadratus lumborum in across fiber direction. So you’re influenced in influencing quite a bit of appropriate sectors there, the golgi, tendon, organs, and such Brian, anything to add, or you want to jump to the next.

I know let’s go ahead. And I think the next one just shows some images of the the needling placement.

All right. So we just described that pretty well. I think you guys can be able to that in the images, these images are from the sports medicine, acupuncture, textbook, and now.

Yeah. So we’ve already discussed the liver five.

So when I was talking about the lumbar plexus and there’s nerves that wrap around some of which intervates the QL, the subcostal ilial hypogastric Leland. We know Matt, do you know if it’s the, I was here, it’s the L and L to a anterior division, anterior. For for QL or at least I’ve seen you indicate that, is that branches off the Leo hypogastric Amelia.

We know. Cause I know those are one L region or are they like before the lumbar plexus ranches off?

I didn’t understand your question because it is the illegal hypogastric Ilian wino. And I do agree that it’s the ventral Rami. That’s how it’s talked about, but what is, okay. What was the question?

My question is sometimes I’m just seeing reference to L one and L two and I wasn’t sure if it was before.

If it was the, ventral Ray mine, Aramco Ramey, before they get to the lumbar plexus. And there’s like a motor nerve that branches off before intermingling with the lumbar plexus, or is it post lumbar plexus? gastric then it’s, definitely post lumbar plexus. I don’t know. It’s gonna be one more thing for us to be able to go research.

Anyways, those have an intimate relationship with the QL and it is intriguing. The re pain referral, the trigger point referrals. Many folks here are probably work with trigger points, or maybe use them as, a part of the assessment. I use them. That’s not the air, the only thing that can refer and cause pain.

But I think it’s a a useful thing to look for. Especially QL is so frequently involved with a lot of low back pain patterns. And when you look at the the QL referral pattern pretty much goes to where those sensory divisions of the nerves. To the lateral posterial lateral gluteal region to the greater trocanter region, wrapping around to the suprapubic region and then wrapping around to the groin.

There’s also some divisions that go really more posterior deep into the gluteal SSI joint or into the, kind of deep buttock region. But to me that. It doesn’t really talk about it this way and literature, when you talk about trigger points. But to me, that sort of emphasizes that segment has become irritated.

The QL has maybe the QLC irritating factor. Maybe the QL is part of the irritation of that segment, but the sensory division of that complex, so to speak has, been irritated. Maybe that’s, open to debate. And I haven’t seen it quite some depth that way and discussion of trigger point sensitization, but it would make sense to me because there’s such a neurologically intimate relationship between those nerves and the quadratus lumborum.

But to me that also speaks to the the possibility or at least a possible mechanism of how liver five it’s so effective for the QL is that. Working with that collateral circulation being the the low connecting point, it’s working with that collateral circulation that is referring pain, both to the gallbladder channel distribution and the liver channel distribution.

It’s has a referral that’s between these two internally externally related channels. And it’s interesting that it’s the low connecting point that would have. It’s such a, strong relationship in terms of removing pain from the quadratus lumborum and helping with that pain referrals, sensitization.

And then this is something that I’ve been working with in that I started adding liver three, and that seems to really increase the effectiveness on liver five by itself is quite effective, but liver three, yet the low point on that channel is just even a stronger treatment. So this is a really great disciplined.

Combination that you can use in combination with the local noodling. Let me just covered for that side where the TQL is really a pain generator. Yeah. For something like that.

It’s interesting to see the image, the trigger point image that’s on top there on the upper. You can see where the X’s are at Yan and pagan and that reasonable.

These points have been needled for thousands of years or have been known to be a referring type of point a trigger. And then the points lower. Let’s see the deep ones. Is that around you be 23 regions, that upper one. Cause the other one looks like it’s close to almost. Yeah. So

This, is what first of all, let me give a quick statement that this is the old edition of travails book, because I think that, I think it’s the third edition, the newest.

Addition, they’ve taken out these exes because trigger points can inform anywhere in the muscle. I kinda like the, I kinda the Xs, but it’s around for Lark. Chevelles passed, on now. So the decision was made after the fact that I guess they’re basing it on ongoing research and such, but they made the decision on the third one, which is I understand the decision to take out the Xs.

So I think the X’s aren’t. That this is where the trigger point is going to be in this referral, but it’s just tendencies. It’s if there’s a tendency for that upper, especially more lateral fibers to have this that’s marked one to have this referral, which I find is pretty commonly the case that it refers pain that’s, where that trigger points.

So it lives in more of that lateral edge of Yon tends to have more of that number two district. Then, if you go deeper, you advance the needle deeper. And your question, Matt, I wonder the same thing. Are you actually hitting those medial fibers of the QL? Are you starting to get into attachments of the multi-fit eye?

Cause they blend so much together. We’ve seen that a lot on cadaver specimens, but those are the ones that tend to refer deeper down. And I wonder that same aspect. QL or if it’s the relationship of the QL to the , which are on the same layer that I think that

Be really interesting the next time that we get an opportunity to dissect this, Brian is to follow the subcostal nerve into the motor entry point.

And then if we have time to do this would be great is to see if, and then do intramuscular dissection and just follow where it starts to buy for Kate. Is that smaller, small branch traveling intramuscular going to. Yeah, Yon and P going to be fascinating to see if we could follow it up there. Got you. In our system.

We’re really geeky. That’s why, by the way, that’s why I liked the Xs. Cause I think that’s what the X is. That tendency is probably more intramuscular sort of international

sites. Dr. Trevell is probably rolling in her grave because if they’re going to take those exits, I don’t know.

All right. An interesting that channel discussion, but it’s a really effective treatment.

Pate QL. We’ll give it a try. Yeah. Before you actually needle QL, especially Yon seems to be really highly effective. This way is palpated to get a pain scale from your patient. Let’s say, oh that’s, a seven. When you really get on that, that really gets to the source of the pain needle liver five liver three, and then go back and palpated and see what happens.

And I think you’ll find that if you get a really good cheap response to those disappoints, that in and of itself reduces pain by 50% or more. And then the rest you’re getting the the, local needs. It’s a really big part of the full treatment.

It’s good.

All right. We teach a lot of myofascial release techniques in the program especially like targeted ones that really supplement the treatment. And this is a a myofascial release technique for the quadratus. Lumborum especially getting to that lateral edge. If you try to reach the QL through the erector spinae, good luck.

That’s a really. Layer, especially in the lumbar region of tissues. So it’s maybe you can touch it. But you’re going to have minimal influence on it with your fingers. It’s you can needle in there, but it’s hard to determine the depth, cause you don’t know exactly where you are when you’re just going perpendicular.

That’s why the needle technique matchup is going more from lateral to medial, almost the same way my finger is there, but he was showing it with the person in a prone position. So this will be very much like the the needle technique as well. Anterior to the , I’m pretty much at Yon rubbed up right against the iliac crest.

You can angle your finger. Once you get a really deep contact there and engage the tissue, you can angle that pressure up towards the 12th rib and have the person reach their leg down to bring the hip down. So their thigh, you can’t see it fully in this image, but their thigh is in line with their.

So as they reached their foot, say, let the towards the back wall or something straight in line with the torso downward, that’ll start to pull the hip down while you’re spreading and moving that tissue towards the 12th room. So you’re elongating one direction is there, their forest is going the other direction.

And you can take that up to the tall throne. Then you could change directions because of those different fiber orientations. You can change the orientation then down towards the iliac crest and have them reach their. Upward to pull the rib cage up. So you’re decompressing the tissue away from the 12th rent on, and then bring the tissue down towards the Lem.

Is there having a force in the opposite direction, really effective technique after a needle lane and it can help return that tissue to a really good resting length.

Yeah. There’s a lot of good techniques in that class. Yeah. A lot of good ones to use. Same thing with my techniques and same thing with needle techniques is there’s a lot of good exercise techniques as well, trying to be able to accomplish on reinforce your treatment.

I’m thinking about it still as excess and deficiency is when you have a locked short muscle, it will act like it’s excess, but it will be an underlying deficiency when you have a lock long-term. It acts as a deficiency. So it’s a good idea to once you reestablish the channels and the CIM blood and the axle plasmic flow, and we discuss in the actual muscles and the channels themselves.

It’s a great idea to go ahead and strengthen the. It’s long muscles and then try to be able to stretch those lock short muscles. This is one particular stretch is one of our favorites as well. That’s a patient favorite as well. The figure for spinal rotation, where you have the ability to eat long gate, the quadratus lumborum, you can see on the lower photo that she has crossed over that figure for a position.

So her right foot is on the floor and the lateral aspect of her leg, and also thigh is going to be on the floor. So for her to be able to bring her right knee into hip AB duction that helps to lock down and pull down that ilium that could be elevated and causing a shortening of the quadratus.

Lumborum so great exercise to be able to use, like I said, it’s a patient favorite. It helps to release the quadratus lumborum as well as to activate that glute medius, which is going to end up being part of that lateral sling that we briefly talked about. And we’ll talk about it quite a bit more. Yeah. A two hour lecture coming up in just a couple of months on the quadratus.

Lumborum Brian, I think that’s it, man. We went way over time. I hope that. Okay. We have references as well. You guys, we also have something in the notes that you can buy. You guys can go ahead and take a look. We have a number of different recordings. About 75% of our smack program is now. And also on loss at OMS, which is great.

Also the psoas class, the three-hour class that Brian and I did just this last January, that’s available as well as part of the acupuncture anatomy series. LASA OMS also carries a sports medicine, acupuncture textbook, which is the next slide. And so I think we’re probably good to go.

Brian, anything else that you want to be able to quick?

This has classes is great on a Lhasa and it’s much more comprehensive because we have more. But there was no, we did do a, C a. So as if you want to get a little taste for that class that wasn’t, I knew you remembered November. So if you go on a C’s page, you can search back for the the, so as webinars we did there also, so that’s a give you a sort of a sample of that, class, and then you can see it through AAC’s page,

which we always appreciate them having us on and, a

thank you to both an Acupuncture Council. Yeah, absolutely big, huge. Thank you for having us and supporting us. Thank you so much for that, Brian. That was a good call to be able to bring that back in. So that’s good. Anything else, Brian? Ah, Lauren Brown.

Yes. He’s going to be here next week. Make sure you check him out. He’s. A big professional in our field, a wonderful academic and an amazing practitioner. So check him out. He always has really interesting things to be able to say, thank you very much. American Acupuncture Council Brian, always nice hanging out with you.

I’ll talk to you again soon. All right. Bye everybody.