Continuing Education Activity

Lumbar somatic dysfunctions appear when any of the lumbar vertebrae are moved from neutral. These positions include being rotated, side bent, flexed, and extended. Lumbar somatic dysfunctions are common in persons with chronic back pain. This activity outlines the evaluation of lumbar somatic dysfunctions and treatment with counterstrain and facilitated positional release and reviews the role of the interprofessional team in improving care for patients with this condition.

Objectives:

• Identify the indications for performing lumbar counterstrain or facilitated positional release.
• Outline the typical presentation of a patient with a lumbar somatic dysfunction.
• Describe the steps of performing lumbar counterstrain or facilitated positional release.
• Explain the importance of collaboration and communication amongst the interprofessional team to improve outcomes for patients affected by lumbar somatic dysfunctions.

Introduction

The lumbar spine is involved in a myriad of duties, including weight-bearing, providing a sound structure that allows for locomotion, and upholding the spinal neural structures. With constant motion and close proximity to a network of nerves, the lumbar spine is a common source of low back pain. Low back pain is common in the adult population. Some estimates show that 84% of the adults in the United States will experience low back pain at some point in their life.[1][2][3] A metanalysis has found that Osteopathic Manipulative Treatment (OMT) can significantly reduce lower back pain.[4] 

There are a variety of Osteopathic Manipulative Treatments (OMT) aimed at reducing lower back pain, two of which include counterstrain (CS) and facilitated positional release (FPR) techniques. Both of these techniques are considered to be indirect techniques, meaning they take the patient away from the restrictive barrier. The basis of the CS technique is identifying the inappropriately hypertonic, or shortened muscle belly, which causes an excessive amount of discomfort during activation or palpation. CS aims to relieve the muscle’s tension indirectly. To achieve this, the muscle is placed in a position of ease for a sustained period.[5] FPR is a similar indirect technique that places the somatic dysfunction in a neutral position and adds an activating compressive or rotational force.[6]

While focusing treatment on the lumbar musculature, it is important to evaluate and treat the adjacent axial skeleton and spinal segments. A full osteopathic treatment should consist of evaluating the surrounding structures such as the thoracic spine, sacrum, and the pelvis for alleviating and preventing further lumbar somatic dysfunction and associated back pain.[7][8] This educational paper aims to educate on these two osteopathic treatment modalities for lumbar somatic dysfunctions: counterstrain and facilitated positional release.

Anatomy and Physiology

Thirty-three vertebrae make up the entirety of the spine. Each vertebra is shaped differently and can group into cervical, thoracic, lumbar, sacral, and coccygeal.

The lumbar spine consists of fine boney vertebrae that follow a similar shape. Between each vertebra, there is a fibrocartilage intervertebral disk that provides cushioning. The anterior surface of the bone is the body. Most of the weight of the spinal column is placed here. Since the lumbar vertebrae are towards the caudal end of the spine, they carry most of the most bodyweight and are thus thicker than the cervical and thoracic vertebrae.

The vertebra arch forms the posterior surface of the vertebrae. The arch consists of a left and right-sided pedicel and lamina. The arch creates a circular opening in which the spinal cord runs through down the length of the back. Many structures project off of the arch.

Two transverse processes project off the vertebral arch laterally, one to the left and one to the right. There is a thick and rounded spinous process that projects off the arch posteriorly in the midline. Four articular processes arise from the arch; two superiorly on the left and right sides and two inferiorly on the left and right sides. Each of the articular processes connects with articular processes from the vertebra above and below it; this allows for the major motion of the lumbar vertebrae to be flexion and extension. 

Since there is a significant amount of movement that can exist in the lumbar spine, individual lumbar segments can move out of place. Each segment can become improperly aligned by being either rotated, side bent, flexed, or extended. With many muscular attachments and nerves surrounding the bones, there is potential for the out of place vertebral segments to cause pain.[9][10]

One of the major functions of the spinal vertebrae is to house the spinal cord. Some nerves run through the spinal cord and exit out the intervertebral foramen. In the lumbar spine, five pairs of nerves emerge from the cord and carry both motor and sensory neurons. These nerves correspond to a vertebra and exit below their corresponding segment. These then provide innervation to structures surrounding the spine. It is important to note the pain pattern the patient describes. Knowing where each nerve root exits and what the nerve innervates will allow the practitioner to target the treatment to the appropriate spinal segment.[9][11]  

To perform a CS or FPR technique, one must find a somatic dysfunction or an area of exquisite tenderness in a muscle, tendon, or ligament. The practitioner then places the patient’s body in a position where the tenderness significantly decreases. In a CS technique, the practitioner holds the position for 90 seconds. To complete an FPR maneuver, the practitioner adds a facilitating force of compression or rotation for three seconds. There are many theories of how CS and FPR manipulation work, but the most common theory is that the tender point exists because of the overstretching of myofascial tissue resulting in a neuromuscular imbalance.[12] This activity causes an increase in the gamma gain of a muscle spindle. The muscle spindle then sends a signal to the central nervous system, which is perceived as pain. Placing the patient’s body in a position to decrease the pain in the tender point decreases the reflex arc and resets the muscle spindle signal.[13][14]

Indications

The indications to perform OMT on a lumbar segment includes the presence of somatic dysfunction in the lumbar segments. OMT consists of two basic categories: direct and indirect techniques. Indirect techniques like CS and FPR put the muscle and or spinal segment in their position of ease. Thus, these techniques are gentler and can be used on almost all patients, including children and the elderly.[15][16] In patients with acute somatic dysfunctions, as would be seen soon after a car accident or fall, indirect techniques are often preferred.

Contraindications

Absolute contraindications

• Absence of somatic dysfunction
• The patient cannot or does not give consent for the treatment
• Local acute fracture in the treatment area [17]

Relative contraindications

• Placing the patient in the treatment position would exacerbate a vascular or neurological condition
• Severe spondylosis with local fusion and no motion at the level treated
• Severe hip osteoporosis 
• Previous hip dislocation
• The patient is unable to give feedback [12]

Equipment

Equipment needed for this procedure includes an OMT table for the patient to sit or lie on and a stool for the practitioner to sit.

Personnel

CS and FPR only require one practitioner to perform the techniques, so the only personnel needed is the practitioner. 

Preparation

Before treatment, the practitioner should discuss with the patient all of the risks and benefits of the procedure as well as any alternative treatments. The practitioner should also obtain the patient's consent.

Once the procedure is explained, and the patient has given consent, then proceed to evaluate the lumbar spine. A thorough evaluation will consist of establishing a pain scale, a visual assessment, muscle strength testing, as well as a range of motion testing for the lumbar spine. These will be critical to be able to compare the progress made after treatment. An osteopathic evaluation should be completed to find any somatic dysfunctions and or tender points. 

Technique or Treatment

Lumbar Counterstrain

The lumbar spine has five anterior tender points and five posterior tender points. The tender points are named for the lumbar vertebra with which they correspond.

Counterstrain is an indirect technique in which the practitioner places the patient away from the restrictive barrier. The basic procedure for all counterstrain techniques starts with the practitioner finding a tender point in a muscle, ligament, or tendon. The practitioner then presses on the tender point with one finger with just enough pressure to blanch the practitioner's diagnosis finger. The practitioner establishes a pain scale, letting the patient know that the tender point's pain is considered 100%. Without moving the monitoring finger, the practitioner moves the patient to find a position where the tender point pain is reduced by 70% or more. This may require fine-tuning the position until the patient feels at least 70% relief. Once that position is found, it is held for 90 seconds while continuing to monitor the tender point. After 90 seconds has passed, the practitioner slowly and passively brings the patient back to neutral and then reassesses the tender point. 

L1 Anterior Tender Point

The patient begins by lying supine on the table. Determine if a tender point exists by pressing medial to the anterior superior iliac spines. If the area is tender, stand next to the table on the side of the tender point. Keep light pressure on the tender point with one finger and bring the patient's knees and hips into about 90 degrees of flexion. If desired, the practitioner may bring their leg up to the table and rest the patient's legs on their knee. Hold the position for 90 seconds, then bring the patient's legs back to neutral and reassess the tender point. 

L2 Anterior Tender Point

The patient begins by lying supine on the table. Determine if a tender point exists by pressing medial to the anterior inferior iliac spines. If the area is tender, stand on the opposite side of the table of the tender point. Keep light pressure on the tender point with one finger, with the other hand, bring the patient's hips and knees into about 90 degrees of flexion and rotate the hips 60 degrees away from the tender point. Hold the position for 90 seconds, then bring the patient's legs back to neutral and reassess the tender point.

L3 Anterior Tender Point

The patient begins by lying supine on the table. Determine if a tender point exists by pressing laterally to the anterior inferior iliac spines. If the area is tender, stand next to the table on the side of the tender point. Keep light pressure on the tender point with one finger, with the other hand, bring the patient's knees and hips into about 90 degrees of flexion and slightly rotate the legs toward the tender point. If desired, the practitioner may bring their leg up to the table to rest the patient's legs on their knee. Side bend the patient's spine away from the tender point. Hold the position for 90 seconds, then bring the patient's legs back to neutral and reassess the tender point.

L4 Anterior Tender Point

The patient begins by lying supine on the table. Determine if a tender point exists by pressing below the anterior inferior iliac spines. If the area is tender, stand next to the table on the side of the tender point. Keep light pressure on the tender point with one finger, use the other hand to bring the patient's knees and hips into about 90 degrees of flexion and slightly rotate toward the tender point. If desired, the practitioner may bring their leg up to the table to rest the patient's legs on their knee. Side bend the patient's spine away from the tender point. Hold the position for 90 seconds, then bring the patient's legs back to neutral and reassess the tender point.

L5 Anterior Tender Point

The patient begins by lying supine on the table. Determine if a tender point exists by pressing on the respective the pubic ramus, just lateral to the symphysis. If the area is tender, stand next to the table on the side of the tender point. Keep light pressure on the tender point with one finger, use the other hand to bring the patient's knees and hips into about 90 degrees of flexion. Bring the patient's far ankle to cross over the nearer ankle and spread the knees slightly apart. Hold the position for 90 seconds, then bring the patient's legs back to neutral and reassess the tender point. 

L1-5 Posterior Tender Point

The patient begins by lying prone on the table. The posterior tender points for L1-5 can be located on the spinous process, transverse process, or in between the two on the corresponding lumbar segment. Locate a tender point and stand on the side of the table opposite of the tender point. Lift the leg on the side of the tender point. If the tender point is midline extension may be enough if the tender point if further out toward the transverse process, pull the leg into adduction. Hold the position for 90 seconds, then bring the patient's leg back to neutral and reassess the tender point.

L3,4,5 Upper Pole Tender Points

The patient begins by lying prone on the table. The L3, L4, L5 upper pole tender points can be located 2/3 linear distance from the posterior inferior iliac spine (PSIS) to the tensor fascia latae, the posterior edge of the tensor facia latae, and superior and medial to the PSIS, respectively. Locate a tender point and stands on the side of the table opposite the tender point. Lift the patient's leg on the side of the tender point and pull the leg into adduction. Hold the position for 90 seconds, then bring the patient's leg back to neutral and reassess the tender point.

Lower Pole L5 Tender Point

The patient begins by lying prone on the table. The lower pole tender point for L5 can be located inferior to the PSIS. Locate a tender point and sit on a stool on the side of the table of the tender point. Drop the patient's leg off the table and bring the knee and hip into about 90 degrees of flexion. Adduct the thigh by bringing the knee in towards the table. Hold the position for 90 seconds, then bring the patient's leg back to neutral and reassess the tender point.

Lumbar Facilitated Positional Release

FPR is also an indirect technique where the practitioner places the patient away from the restrictive barrier. The basic procedure for all FPR techniques is to find a somatic dysfunction, monitor the dysfunction with one finger, then place the patient's body into a position of ease. This will hyper-shorten the muscle or exaggerate the dysfunctional vertebra and allow the muscle spindle to decrease its output. Lastly, a facilitating force is applied by adding compression, torsion, or a union of both for three seconds. The facilitating force is released, and the patient is returned to neutral, and the monitoring finger can let go to reassess the somatic dysfunction. 

Low Back Superficial Muscle Hypertonicity

The patient begins by lying prone on the table. Straighten the lumbar lordotic curve by placing a pillow under the patient's abdomen. Locate an area of lower back superficial muscle hypertonicity and stand on the side of the hypertonic muscle. Monitor the hypertonic muscle with one finger. Move the patient's legs toward the side of the table of the hypertonicity until motion is felt under the monitoring finger. This will induce lumbar side bending toward the side of the hypertonicity. Cross the patient's farther leg over the closer leg to induce more of a side bend. Hold the patient's farther thigh and rotate it externally while extending the thigh. Keep moving until motion can be felt with the monitoring finger. Hold the position for three seconds. Bring the patient's leg back to neutral and reassess the hypertonic muscle.

Lumbar Segment Extension Dysfunction

Assess the patient's lumbar spinal segments for an extension dysfunction. Once an extension dysfunction is found, the patient begins by lying prone on the table. Straighten the lumbar lordotic curve by placing a pillow under the patient's abdomen. Place a second pillow under the thigh in which the spinal segment is rotated, and side bent towards (e.g., for an L3 Extended SLRL segment place a second pillow under the patient's left thigh). Stand on the side of the table towards which the spinal segment is rotated and side bent. Monitor the most posterior transverse process of the dysfunctional vertebra with one finger. Bring the patient's closest leg into abduction and internal rotation until motion can be felt at the monitoring finger. Internal rotation is achievable by grasping above the patient's ankle to rotate the leg. Then press the leg down toward the floor until motion can be felt at the monitoring finger. Hold the position for three seconds. Bring the patient's leg back to neutral and reassess.

Lumbar Segment Flexion Dysfunction

Assess the patient's lumbar spinal segments for a flexion dysfunction. Once a flexion dysfunction is found, the patient begins by lying prone on the table. Straighten the lumbar lordotic curve by placing a pillow under the patient's abdomen. Sit on a stool on the side of the table in which the spinal segment is rotated, and side bent towards (e.g., for an L3FSLRL dysfunction sit on the left side). Monitor the most posterior transverse process of the dysfunctional vertebra with one finger. Bring the patient's closest leg off the table. Holding the patient's knee, bring the patient's knee and hip into flexion until motion can be felt at the monitoring finger. Then press the patient's knee into adduction and internal rotation of the hip until motion can be felt at the monitoring finger. Hold the position for 3 seconds. Bring the patient's leg back to neutral and reassess.

Complications

CS and FPR are two of the most gentle osteopathic techniques. Practitioners should warn their patients of possible soreness and stiffness to the area, which is not uncommon considering the dysfunction. It is also important to discuss reasonable outcomes after the treatment and the need for possible repeat applications due to the nature of their dysfunction. 

Clinical Significance

Low back pain is a common reason for an individual to see a healthcare provider. Some estimates say there is up to a 70% prevalence of low back pain in affluent countries.[18][19] Treating back pain can also become expensive with some diagnosis requiring things such as imaging, costly procedures, medications, and physical rehabilitation. Besides being potentially financially draining, lower back pain can have negative psychological effects and is associated with a depressed mood and emotional distress.[20] Treating a patient with OMT not only provides immediate care and possible relief from pain but also can reduce the cost of care for a patient that is trying to avoid surgery or other costly procedures.[21] 

Enhancing Healthcare Team Outcomes

Lower back pain can stem from a multitude of causes and create a significant cost on the patient, and healthcare, as a whole. These can include but are not limited to spinal fracture, tumor, herniated disk, stenosis, rheumatoid arthritis, and somatic dysfunctions.[19] While the practitioner may initially be the one to diagnose a patient with lower back pain, there is a team of professionals needed to consult, further treat, and keep in contact with the patient. When a patient presents with back pain, it is important to obtain the vital signs which may be performed by a nurse. Imaging may be required; in this case, a radiologist will be essential to come to a diagnosis.[22]

Once a diagnosis has been reached, the care for the patient needs to continue. Analgesics, antibiotics, or other medications may be necessary. A pharmacist will be necessary to dispense and confirm that the patient is on the correct medications. If bracing or other assistive devices are needed, a nurse will be the one to educate the patient on the proper way to use the equipment. A physical and or occupational therapist may be necessary to help the patient recover mobility, strength, and coordination.

Besides working to regain physical function, chronic back pain can have a negative psychological effect on the patient.[23][24] A psychologist may be recruited to treat any further compounding or secondary conditions due to the lifestyle caused by the dysfunction. Working as an interprofessional team will ensure that the patient's goals, expectations, and health are properly optimized, thereby reducing the morbidity and mortality.[25] [Level 5]