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Acupuncture Malpractice Insurance – Lumbar Pain: Supplementing Acupuncture with Therapeutic Exercise

 

 

Today I would like to show a side bending exercise I give with patients frequently in the context of treatment of low back pain, especially when the facet joints and the QL is involved.

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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.

Hi, this is Brian Lau. I’m with Jingjin Movement Training, also an instructor with Sports Medicine Acupuncture Certification Program. So thanks to American Acupuncture Council. I always appreciate doing these webinars. A lot of fun to get together and share some information with you. Today we’re going to be referring back to the last presentation I did.

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We talked about the internal pattern, talked about the Zhui Yin and Xiao Yang channels in general. We looked at it in relationship to rotation. We even looked at a rotation exercise. Today I would like to show a side bending exercise I give with patients frequently in the context of treatment of low back pain, especially when the facet joints and the QL is involved.

It’s a great exercise, great to add to your repertoire when treating patients. It’s actually a great exercise to do for your own health. You get a twofer, you get something you can practice for yourself if you don’t have a good side bending exercise, but then something you can use to, to, as part of the treatment.

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So it’s an exercise that patients can do at home, yes, but as much as anything, I use some equipment for this. is it’s an exercise that I do after treatment to supplement the treatment to help open the tissue that I worked on with acupuncture manual therapy. So let’s go to the presentation.

We’ll start going over some some introductory information, a little bit of anatomy, and then we’ll look at the movement. Let’s talk about the quadratus lumborum, not the only muscle in the low back that causes low back pain by any means, but it’ll be a little bit of the star of the show for today.

And this exercise can work for a lot of different things, but when the QL is involved, it’s a really great exercise specifically for QL. Type pain. So this is the trigger point referral pattern of the quadratus lumborum. You can see some of the trigger point referrals can be out to the gallbladder channel, along the side, even to the greater trochanter.

They can wrap around to the liver channel. Sometimes the deeper fibers can go towards the SI joint or glute area. But by and large, it’s gallbladder and liver distribution. Now it’s interesting to me because I see, and we’ll look at a brief picture in a moment with the anatomy, I see that the liver, I somborum is part of the liver sinew channel which is a little higher up than the channel is classically described.

We’ll talk about that briefly. But interestingly also is liver V as a distal point, I do treat it locally local treatment is extremely important when you’re working with low back pain when the QL is involved. But as a distal point, liver V, the low connecting point, is a very useful point that becomes very reactive with QL pain.

And it’s interesting that this low connecting point treats this muscle that has a referral both to its its Xiao Yang partner, the gallbladder channel refers to the gallbladder channel, but it also refers to the liver channel. So its referral seems to be between those two those two related channels and the low connecting point would make sense that it would become reactive in that case.

So let’s look briefly at the QL anatomy. This is from Matt Callison’s Motor Point Index. He also has it in his Sports Medicine Acupuncture text. A great book if you don’t have it. This shows the iliac crest attachment, the 12th rib attachment, but also fibers that are going to transverse processes.

It’s a very complex muscle, multi layers. There’s actually three layers of the quadratus lumborum. We did a class on this that’s available on Net of Knowledge, and we talked about all these layers and different fascicles. It’s an interesting muscle. to spend a little more time on that we don’t have time today, but just to highlight that it does have attachments on those transverse processes and the 12th rib and the iliac crest.

It communicates with the multifidi muscles that also attach to the transverse processes and those muscles then go to the spinous processes. So this exercise we’ll be looking at would work those muscles too, but what really I want to highlight in this image in addition to the QL is the facet joints.

We’ll come back and talk about those in a second, but you can see them really well on this illustration. This is where the main movement happens from vertebra to vertebra. Facet joints are also called zygopaphyseal joints and these can be pain generators themselves. When there’s pain associated with a QL, multifidi, and or, and it’s often a and the facet joints this will be a really good exercise to complement it.

So the facet joints of the spine have a coupled relationship between side bending and rotation meaning that they both they, when they do one or the other, they do both. So when you’re side bending, there’s also a rotation component when you’re rotating the individual vertebrae can side bend.

And in particular, the lumbar region has limited rotation just by design. The facet orientation has limited rotation. So we’re going to be doing side bending to really exercise and move those facet joints. So if there is facet joint pain, moving the facets will help open that tissue up and help desensitize that tissue.

But when you’re moving the facets and sidebending, you’re also stretching and contracting, depending on which side you’re sidebending to. Stretching and contracting the quadratus lumborum, and you’re somewhat activating the multifidi also. So nice to know that these coupled relationships exist because really a good comprehensive program will include both sidebending and rotation.

We’re going to look at sidebending today. Here’s the liver sinew channel, so classically it ends at the groin, following up the adductors, adductor longus, pectineus, adductor brevis, gracilis, adductor magnus in my mind is part of the liver sinew channel, it’s more posterior, has a different fascial plane that it lives in, but we’re going to be looking more at those anterior adductors.

I also have in the list the lower portions of the channel, including the flexor digitorum longus, which is what you’d be needling into if you need a liver 5. So that would be affecting that fascial plane. And classically that ends at the groin, but if you follow that fascial plane up, it goes into the psoas, the iliacus, and the QL, all part of that plane, even though we access the QL from the back, it’s much more of a central muscle.

It’s on the fascial plane of the adductors. That would follow really all the way up to the diaphragm. So you can take that channel, in my opinion, up to the diaphragm. But QL is a big player in that and common cause of low back pain. So it’s important to understand these pathways. So liver organ itself has a particular movement that’s going to play into this.

So we looked at rotation at the last webinar I did with the American Acupuncture Council. So in the transverse plane, there’s a rotational movement of the liver in relationship to the diaphragm and the organs around it, like the stomach in particular, kidneys too. There’s a movement in the sagittal plane where it’s tilting forward, tilting back.

Those are going to be exercised much more with rotational type exercises. I want to look at this frontal plane movement. So the frontal plane movement, the liver moves in relationship to the left ligament that holds it up to the diaphragm. And as you side bend to the left and that liver flares up, you want it to be able to move in relationship to the tissues around it, like the transverse colon, the stomach, et cetera.

Then it can also rotate down so it can have a movement in that frontal plane that we’re going to be really highlighting in the rotation exercise. So you’re going to be stretching and contracting the QL, you’re going to be mobilizing liver, you’re going to be opening and closing the facet joints.

It’s important to do sidebending activities because they are underutilized and they’re extremely important for low back health and liver health. Alright, real brief, I’m not going to go into a lot of needle technique for the QL, it takes a little bit more time than I have here today, but I just wanted to highlight a couple directions that you could look at if you’ve had some training with the liver I mean with the liver sinew channel with the QL.

I can needle through this fibrous part of the thoracolumbar fascia where all the abdominal muscles meet, at least all their fascial compartments meet. And then it separates into fascial compartments that wrap around various aspects around the erector spinae and between QL. This is called the lateral raffae.

It’s the lateral seam of the abdominal muscles before they separate into various layers of the thoracolumbar fascia. So I can angle a needle into that. Sometimes that tissue is pretty reactive in and of itself. And that’s my target tissue. Or I could go through that and touch the QL. If I’m trying to needle the QL, I usually just go straight lateral, parallel with the table of the person was lying prone.

If they’re lying sideline, it would go straight towards the table, perpendicular to the table. So there’s some instructions here. If you go back and watch this, you can freeze here and look at those. I, again, this isn’t an instructional webinar on needling that. I just want to give some highlights real quickly here.

I’m palpating into that lateral raffae. So you can see I have about a 30 degree angle or so towards the table. So I’m at the edge of the iliocastalis lumborum advancing the needle into that lateral raffae. Maybe I touch the iliocastalis lumborum. Maybe I touched the quadratus lumborum. Maybe I’m in that fascial seam, which is my target.

And I think what happens is when I hit that fascial seam and engage that, it’s gonna pull on whatever structures it needs to. But it’s just a very reactive place and I needle the lateral raphe quite frequently based on palpation. If my goal is to needle the QL, I’m going to go more parallel to the table, directly cross fiber to the QL or needle it sideline.

I’ll have the leg extended to help depress the ileum on that side and then go straight down towards the table. This is my preferred way of needling the QL if I want to cross fiber the QL, but I might do it prone if I want to combine it with other points, for instance. All right I have some of these types of exercises, including this exercise, but I want to redo the video.

I have it on my YouTube channel, JingJin Movement Training, there’s a QR code there. I haven’t put short samples of those on my Instagram page too, so you can follow that if you’re interested in more information. But I want to now go and show some instruction for this particular exercise that you can use in your treatments.

So I’m going to exit out, and I’m going to back up, so give me just a moment.

Alright, so let’s initially, minimize something, sorry. Let’s talk about equipment first of all. So I’m going to show you two things that I use for this. This is a product called, from a company called StickMobility. StickMobility. StickMobility. com So I like the, I really think this is a solid product. I have them.

I, it comes in a set of two of these. This is a six foot one. I’m not super tall. If you’re taller, I’d get the seven foot one. So I’m about five eight. This one’s going to work for the exercise I’m going to show you quite well. But if you’re six foot tall or something like that, I would go ahead and get the seven foot tall one.

It marks them pretty well on the webpage. So it comes with two of these and it comes with a shorter one. I will say they’re a little pricey. So if you’re not going to use them a lot, I paid 180 for them. That was before greenflation or whatever we want to call it. So they’re probably, I haven’t, I meant to check before the webinar.

They’re probably 200 or 220 or something like that. Now it’s worth it. If you’re going to use them a lot, they’re very solid. They’re not going to break on you. For this particular exercise though especially if you’re going to give it to patients, I think it works just fine with PVC pipe. So with this PVC pipe, I put a little chair stand, whatever these are called that goes on the ends of the legs of the chair.

So I put those on the end because I wanted to be able to grip the floor so that this works out pretty well. These are just little rubber stoppers but the PVC pipe’s pretty strong. So this would be, I don’t know, 10, 15 or something like that. It takes you a little time. You have to go get it and find the appropriate stoppers for it, but it works out just fine.

So I’m going to use the stick mobility one since I have it, but this would be perfectly fine. I’ve never had a problem. PVC pipe’s pretty strong. I’ve never had a problem with that breaking. But I guess that is a consideration if you have a professional product, maybe from a liability standpoint. So maybe in your own office it’s worth having these, but if you’re going to give it to patients and they’re not willing to buy something that’s 200 and they’re only going to do this one exercise, I think the BBC pipe would be a really adequate way of doing it.

But you can also just give this in your office as a complement to the treatment, even if they don’t do it at home, at least they’re engaging that tissue that you just addressed with the acupuncture. So let’s get this set up. I want this to be somewhere about a foot away from my side of my foot. I don’t know, maybe with the metatarsals, doesn’t really matter.

It’s somewhere along the side of the foot, about a foot away. This exercise is easier the farther I move it away. But you’ll see as I go into side bending, if I have it too far away, it’s going to slip. So I need to have it close enough to where it grips. So that’s going to be a little bit of a challenge.

If it’s too hard, you need to move it away. But if you move it away too far, it’s not going to work so well. So about a foot is a good happy medium. So I’m going to put the Stick down. I’m gonna get my arm about at a 90 degree angle at the elbow. I’m gonna reach up, palm facing forward. So if I open my palm up, it’s facing forward.

Grab around. This is where if I was too tall, I’m gonna be like this. I’m not gonna be able to get my head under when I go to do side bending. So it needs to be high enough up to where I’m comfortable. Okay, so I want my chest to turn slightly Towards the bar, and what I’m going to do is I’m going to push out with the lower arm.

I’m going to let the top arm straighten, and I’m going to turn my chest forward. So that’s the position. I need to turn. So I’m pulling with the top arm, but I’m not pulling with the elbow. I’m pulling with the shoulder blade. And then I’m pushing out and extending out. So you can see it gives a really nice stretch all the way through the spine.

For Especially the lumbar spine, very complimentary for working with facet type pain and QL type pain. Come out of it slowly, I can turn my chest back, forward, and relax. So it does take a certain amount of strength for this. This one’s not overly, requires a lot of strength. It’s somewhat also positioning and learning how to use your whole body.

People mostly are trying to use the arms and it’s very difficult for them to push. I’ll show you how I assist them and help them in a second, but part of it is learning how to turn the chest and side bend into the, how to pull with the shoulder girdle without pulling with the arm. That’s going to shorten everything.

I need to pull my scapula back on that side, push the arm out on the bottom one, and then just lean and let it start to bend through the torso. Okay, I’ll show it on the other side and then I’ll show you how I help patients with it. So again, set up about a foot away, arm down, out about hip level, we’ll say about a 90 degree angle thereabouts, maybe slightly lower.

You can adjust it as you go for comfort, palm facing forward. Behind the bar, behind the stick, grab a hold, face my chest towards the bar, or at least in that direction. So I’m rotated in this case to my right, I don’t know if that’s going to show up because sometimes things get a little weird imaged on the webinars, but I’m facing to my right.

This is my right hand at the lower portion, and then I need to turn my chest forward. So I’m turning slightly to the left. Project, pull

the shoulder blade back, my left arm on my top arm, push out with my bottom arm, let everything side bend,

and slowly turn back when I’m ready, and there you go. So how I help. So let’s say I’m back on this side.

Patient can’t really do, first of all, the most often what they’re doing is they’re going to bend the top arm because they’re trying to pull. They need to learn how to let the lats lengthen, let that arm straighten, turn the chest. So it’s a little bit of a difficulty. So imagine I have a patient who’s struggling with this activity here.

I could be on the other side. I usually brace this with my foot and I help them. I’m not just pulling them through it. But I’m giving them some assistance and guiding them, let your top arm straighten, okay there you go, and then I’m helping pull them. Now, once they get into the stretch as far as they can get, I don’t want to just let go when they come out of it.

So I’m pulling, guiding them through it. Their chest is facing forward. Okay, so let’s come out of it. I’m slowly letting up as they turn their chest forward, especially if they have back pain. I don’t want it to be a very jarring activity where they’re in a somewhat compromised position and they just let go.

So I’m helping guide them through it. They don’t have to go as far as I went. Maybe they just go a little bit. Maybe they just get to here. But if I can help pull enough to where Pulls on this top arm, they’re going to start to get that stretch down through the lats, and then also into the QL. Highlight the movement.

I would definitely do it on both sides. So if it’s a lot of pain, maybe they only get this far, but usually this feels good for them. So if it is causing a lot of undue pain, I might come back to it in another treatment, but usually it feels good, feels therapeutic, it feels helpful. It feels like it supplements the treatment.

Same thing. I’d get them set up on this side, chest angled slightly towards the direction of the pole, turn the chest forward, push out, and that same thing. I might be over on this other side, guiding them, giving them some help, making sure they feel stable, guiding their positioning, let that top arm straighten.

Let everything stretch, giving them, coaching them through it, and giving them some guidance, helping them find the maneuver. So using the stick makes it really much more effective. Some people do a side stretch, which is great, nothing wrong with it. Or they might do something with the hands overhead, no problem.

Really nice, You can do a lot of the same types of things. There’s a windmill exercise I do, reaches through nice mobilization. I don’t like this one as much for back pain because of the rotation until they get a little bit more farther along the treatment and they can comfortably go in rotation without causing pain.

So there’s other ways of doing it, but the stick is a really guided way that you can work with patients. You can give them that assistance. You can take them through the process. In a little bit more controlled way. And to be honest, having that arm pulled and stretched from the stick really makes the stretch much more easy to access and takes them into it in a much stronger way.

So it’s a simple bit of equipment, even especially if you just got the PVC pipe. We’d recommend at some point, splurging and getting the stick mobility. I think they’re a really good product, but they are a little pricey. But it’s nice to have maybe the PVC pipe one also in your office so you can show patients and give them some recommendations for what to do in their at their own house when they’re practicing that.

But it, like I said, even just doing it that one time after treatment is part of the treatment. That’s how I view it. So I think you can take that same approach. All right. I think that covers the main information that I wanted to cover for this. Give it a go. Like I said, I have some videos on my YouTube channel, JingJin Movement Training.

I’ll make a point to get a new video up with this from different angles so you can see it and review it. But you can also review it from the webinar. That is on American Acupuncture Council’s Facebook page. It’ll also be on my YouTube channel. And if you wanted to go back and look at the rotation exercise I did, those will be at both of those places also, and it’ll give you a complimentary exercise for rotation that’ll also work.

The internal pathways quite nice. So thanks again for American Acupuncture Council. Look forward to seeing you guys at another time.

 

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