I'm Brett DeGoyer. I'm a primary care sports medicine specialist and neuromusculoskeletal medicine specialist practicing for Samaritan Healthcare in Moses Lake, Washington. In this case, we're dealing with low back pain specific to a bulging or herniated disc in the lumbar spine. For manual treatments, we want to decompress that region, and there's a few ways that I prefer to do that using osteopathic manipulative treatment. One way is to just simply come underneath the patient when they're in the supine position and grasp the paraspinal muscles. So as I'm grasping the paraspinal muscles, the spinous processes or the middle of the spine is running up and down my two palms, so my fingertips are then grasping muscle tissue. My thenar and hypothenar eminence on my hands are also grasping muscle tissue and squeezing gently together and then pushing anteriorly just to add some inhibitory effect to those muscles to try to get them to relax. Additionally, if I feel I can do this without putting too much strain on my own upper body strength, I'll add some distraction through my hands, trying to gap those segments in the lumbar spine to try to release that pressure that's contributing to the bulging and herniated disc. I'll spend a good two to three minutes doing that. That really relaxes the patient and helps the pain to settle down. Additionally, I'll go in from the front. So I'll do the same action from the back, grasping the paraspinal muscles with one hand, in this case my cephalad hand, grasping, pinching, compressing anteriorly, and then my other hand will come from the front, just above the pubic symphysis, and I'll compress down through the pelvic bowl to release tension off of the back. That compression helps to relax the muscles that create this tube of part of the core, and since it's a tube, everything on the front is connected to the back. So compressing from the front and compressing from the back helps to relax all of those structures, allowing tension to diffuse or dissipate along the spine, hopefully getting rid of as much pain as possible. If I'm doing that treatment, I'll usually have them bend their knees up just to relax the abdominal wall a little bit better so I can compress a little bit deeper. Go ahead and straighten your legs. The next treatment that I do, or the third treatment, is to once again use my cephalad hand to grasp at the paraspinal muscles, squeeze together with my fingertips and thenar and hypothenar eminence, compress up. My caudad hand will actually scoop underneath cupping at the sacrum. I'll gently compress the sacrum anteriorly and then draw my hand towards the end of the table, towards the feet, again inducing a bit of traction to help release that compression force, that compression that's causing a lot of pain because of the bulging disc, and I'll hold that again for two to three minutes as long as my hand strength can handle it. Let me demonstrate that one. So as I'm coming up underneath, what I'll do first to make it easy on me is I'll bring the knee up, I'll gently rotate their pelvis towards me so that I can reach under and cup the sacrum, and then roll their pelvis back and drop their leg down into full extension. And then I may have to adjust a little bit just to make sure I'm cupping the entire sacrum. Then my cephalad hand is going to slide up underneath right at the L5, L4 location, grasping those paraspinal muscles on either side. And then as I squeeze, I'll induce a little bit of anterior pressure into the paraspinals on my cephalad hand. On my caudad hand, which is cupping the the sacrum, I'll push up and then pull towards the end of the table, towards the feet. This is also a very good technique to have an assistant. And what I mean by that is if you have an assistant who can be in the room, I ask that they participate by grabbing one of the legs or both and just adding traction through the leg, which will further induce traction up at the lumbar spine. And we'll hold that for two to three minutes, giving a lot of relief to that bulging disc. Once I'm done, I slide out and then we recheck, ask the patient how they're feeling. Again, as discussed in hopefully all of our medical training, when you're reaching insensitive areas, you want to make sure to be very specific in educating your patient of where you'll be touching, why you'll be touching in those certain areas, and making sure that they give full consent for you to do so. And making sure that they are comfortable needing or refusing to have a chaperone present when you're doing your treatment.

3rd Edition, CASE 55

3rd Edition

Spine

osteopathic manipulative treatment

low back pain

herniated lumbar disc

decompression techniques

patient comfort