Treatment of a Case of Subacute
Lumbar Compartment Syndrome Using the Graston Technique
by
Warren I. Hammer, DC, MS
Mark T. Pfefer, RN, MS, DC
This
article is featured in Journal of Manipulative and Physiological
Therapeutics.
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Objective To discuss subacute lumbar compartment syndrome and its
treatment using a soft tissue mobilization technique.
Clinical Features A patient presented with low back pain related
to exercise combined with prolonged flexion posture. The symptoms were
relieved with rest and lumbar extension. The patient had restrictive
lumbar fascia in flexion and rotation and no neurological deficits.
Intervention and Outcome The restrictive lumbar posterior fascial
layers and adjoining restrictive fascia (thoracic, gluteal, hamstring)
were treated with a form of instrument-assisted soft tissue mobilization
called the Graston technique. Restoration of fascial extensibility and
resolution of the complaint occurred after 6 treatment visits.
Conclusions The posterior spinal fascial compartments may be
responsible for intermittent lower back pain. Functional clinical tests
can be employed to determine whether the involved fascia is abnormally
restrictive. Treatment directed at the restrictive fascia using this
soft tissue technique may result in improved fascial functional testing
and reduction of symptoms.
It has been established that
pain due to compartmental pressure occurs in various areas of the human
body.1-4
Compartment syndrome is defined as,5
“…a condition in which increased pressure in a confined anatomical space
adversely affects the circulation and threatens the function and
viability of the tissues therein.” The posterior and middle layers of
lumbar fascia create a compartment that bounds the erector spinae
muscles. Most of the case reports dealing with lumbar compartment
syndromes describe an acute lumbar pain syndrome associated with
elevated creatine kinase, the presence of urinary myoglobin, and muscle
edema appearing on Mifi scan.6-8
A prior case report describes successful management of acute lumbar
paraspinal compartment via surgical fasciotomy.7
Paraspinal muscular pressure has
been found to be highly increased in the flexed standing position with
loading in normal control groups and significantly higher in patients
with osteoporosis, degenerative spondylolisthesis, lumbar compartment
syndrome, and previous lumbar spine surgery.9
Lumbar paraspinal muscle pressure has also been found to be
significantly higher in subjects with disk herniation than in controls
when a straight leg raising test was performed.9
It is proposed that some cases of low back pain may be related to this
overlooked condition related to increased compartment pressures.
Dissections in the lumbar region
confirm a clearly defined, well-developed compartment consisting of the
erector spinae muscles encased by the posterior and middle lamellae of
the lumbodorsal fascia.6
The posterior layer of the lumbar fascia is composed of a superficial
and deep layer that covers the iliocostalis, longissimus, and multifidus
muscles (Figs
1 and
2).10,11
Barker10
demonstrated by dissection, for the first time, the connection of the
posterior lumbar spinal fascia superiorly with the splenius muscles. She
found that the superficial fascial layer in the lumbar area maintained a
cross-hatched arrangement of fibers to T12, whereas the deep fascial
layer fiber angles were more consistent in angular alignment. Barker10
concluded that the posterior fascial layer generated tension in tests
involving movements of the entire spine, head, and limbs.
| Fig 1.
Posterior lumbar fascial compartment surrounded
by the posterior and middle layer of the lumbar fascia. The
posterior layers originate medially from the lumbar spinous
processes and interspinous ligaments and wrap around laterally
to join the lateral raphe, the dense union where the posterior
and middle layers meet. The middle layer provides the fascial
anterior border of the erector spinae muscles as it attaches to
the tips of the lumbar transverse processes and is directly
continuous with the intertransverse ligaments.
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| Fig 2.
Three-dimensional view of the posterior lumbar
fascial compartment.
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Bogduk and Twomey12
describe bands of collagen fibers passing from the L4 and L5 spinous
processes to the posterior superior iliac spine and lateral raphe
(“posterior accessory ligaments”) making up part of the deep posterior
fascial layer. The quadratus lumborum muscle lies anterior to the middle
layer. Peck et al13
demonstrated the connections of the posterior fascia by injecting dye
into the paraspinal compartment at various levels of the spine. They
found that the dye traveled freely along a compartment between the
occiput and sacrum, staining paraspinal muscles including multifidus,
splenius cervicis, and capitis muscles.
Vleeming et al14
demonstrated how traction to the biceps femoris caused displacement of
the deep lamina up to the level L5-S1 as load transfer occurred by way
of the sacrotuberous ligament. They noted how tension of the posterior
layer of the thoracolumbar fascia was influenced by contraction or
stretch of a variety of muscles, especially the latissimus dorsi and
gluteus maximus. These tissues are responsible for what is known as the
“force closure” of the sacroiliac joint.
Bogduk and Twomey12
found that a significant function of the posterior layer of the
thoracolumbar fascia was that it resisted the normal expansion by its
increased tension during contraction of the lumbar muscles. They stated
that contraction of the lumbar back muscles increases the tension in the
posterior layer thereby enhancing the antiflexion functions of the
thoracolumbar fascia. This phenomenon is called the hydraulic amplifier
mechanism.15
The posterior spinal fascia passively restricts forward bending. It was
found that intramuscular pressures were dependent on posture. Kyphotic
back posture produced intramuscular pressures of 120 to 130 mm Hg,
compared with the 10 to 25 mm Hg produced when volunteers were in the
erect position.16
Hukins et al17
propose that the lumbodorsal fascia increases the force per unit of the
erector spinae muscles by limiting the bulging of the muscles when they
shorten.7
This case demonstrates reduced
pain and improved range of motion in a patient with lumbar compartment
syndrome after instrument-assisted soft tissue mobilization using the
Graston technique (GT).
A
59-year-old man complained of intermittent lumbar pain of 2 weeks'
duration. He worked as a shoe salesman and became aware of his pain
especially in the flexed lumbar position. His pain became severe every 2
to 3 months for the ensuing year, causing him to miss work 2 to 3 days
at a time. Usually, bed rest and analgesics provided relief. This time
his pain continued and although bed rest still relieved him, the pain
persisted especially when he flexed forward. Bending backward relieved
his pain. He denied any radiation of pain to the buttocks or lower
extremities. The patient had no medical history significant to his
presenting symptoms. Lower extremity motor strength, reflex, and sensory
test results were negative.
The
patient's posterior spinal fascia was stressed by passively flexing the
spine in the sitting position, beginning with the cervical spine and
bending the entire spine in a variety of directions (flexion, lateral
bending, rotation) creating tension down to the left lower thoracic
paralumbar areas (Fig
3). The purpose of the passive stretch was to detect shortening with
the expression of pain and/or abnormal tension. In this case, cervical
and thoracolumbar flexion and right rotation created abnormal tension
caudally to the T12-L2 level on the left side. The same forward motion
with left cervical and thoracic rotation created abnormal tension at the
medial right scapula and right paralumbar L4-Sl levels. Passive forward
flexion evaluated in the standing position caused a complaint of sacral
and hamstring pain and tension. Supine evaluation for restrictive tissue
revealed shortening of his hamstrings bilaterally with tightness and
palpable restriction at 70° and shortening of the external hip rotators
on the right. Ober's sign was negative bilaterally, and the triceps
surae and hip adductors demonstrated normal extensibility.
| Fig 3.
Passive flexion and right rotation of the spine
to determine areas of involvement.
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The patient's superficial and
deep fascia was evaluated and treated by the GT at the areas of
complaint found during the flexion tests and at other related fascial
areas that demonstrated restriction. In addition to treating the
posterior fascia by the GT (Fig
4), the fascia overlying the hamstrings bilaterally (Fig
5), sacrum (Fig
6), and right hip lateral rotators were also treated. Immediate
postfacilitation stretch was applied to the involved areas and taught to
the patient to continue at home (Fig
7).18
Two sets of 3 stretches were recommended twice a day. These exercises
are contraindicated in the morning because of increased disk fluid
content. According to McGill,19
disk-bending stresses are increased by 300% and ligament stresses by 80%
in the morning compared with the evening.
| Fig 4.
Use of a Graston instrument along the paralumbar
fascia.
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| Fig 5.
Use of a Graston instrument along the hamstring
fascia.
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| Fig 6.
Use of a Graston instrument for local release of
tissue in the lumbosacral area.
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| Fig 7.
Postfacilitation stretch for the erector spinae.
The patient flexes forward and pulls his toes with his arms
while extending his head and spine to feel his posterior spinal
muscles to contract. He holds this position for 7 seconds (A).
Next (B) the patient flexes forward and holds the stretch for 12
seconds.
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After 6 visits at 2 visits per
week the patient was discharged. He was asymptomatic and able to
actively and passively flex in all directions without feeling any spinal
restrictions or pain. The functional flexion tests were normal.
Hamstring flexibility and flexibility of the right external rotators
demonstrated significant improved range of motion.
It is not
uncommon to see patients with low back pain whose symptoms are increased
by exercises or activities involving repetitive forward flexion and are
relieved by rest and backward extension. Often, these patients do not
have neurologic deficits in their lower extremities. Styf and Lysell20
mention these symptoms in a diagnosis of “chronic compartment syndrome”
in the erector spinae muscle. The treatment described was fasciotomy of
the erector spinae muscles which normalized the intramuscular pressure.
A microcapillary infusion technique recording the patient's
intramuscular pressure during exercise was used. In another study,
Songcharoen and Thanapipatsfri21
measured the paraspinal compartment pressure by a slit catheter system
connected to a pressure transducer. The paraspinal lumbar muscle
pressure was not directly measured in this study, but as previously
noted, there is a pressure increase in the normal flexed lumbar position
and a “significantly” increased amount in patients with osteoporosis,
degenerative spondylolisthesis, lumbar compartment syndrome, and
previous lumbar spine surgery.
To determine the cause of spinal
pain, it is necessary to pay increased attention to the passive
structures that can be evaluated and treated by manual methods. The
posterior layer of the lumbar fascia is connected caudally to the fascia
which encloses the sacrum, glutei, hamstrings, and gastrocnemius
muscles, and superiorly to the fascia enclosing the erector spinae,
latissimus dorsi, and rhomboids up to the occiput by way of the tendons
of the splenius cervicis and capitis.11
By way of the interspinous-supraspinous-thoracolumbar ligamentous
complex,22
a direct connection has been shown between the thoracolumbar fascia and
multifidus sheath to the facet joint capsules. It is theorized that
“freeing” posterior lumbar fascia and its connections both superior and
inferior could also result in easing the pressure on lumbar facets. As
the multifidus muscles and the facet joints are innervated by medial
branches of the posterior rami, facet joint pain may produce a reactive
constriction that increases intramuscular pressure, temporally
decreasing blood to the multifidus muscles.9
Restricted posterior lumbar fascia may have a direct effect on
increasing the compartmental pressure of the erector spinae muscles.
Fascial restriction likely increases intramuscular pressure in the
erector spinae muscles.
There are several tests for
screening for shortened erector spinae. First, the patient may sit at
the end of a table with the knees flexed at the edge to relax the
hamstrings. The examiner places his/her hands flat on the lateral iliac
crests with the thumbs on the posterior iliac spine. The patient is told
to flex the neck first and curl the body forward, starting with the head
progressing forward followed by flexion of the thoracic and lumbar
spine. As soon as the examiner feels the pelvic movement, the patient is
asked to hold his/her position. If the distance between the patient's
knees and forehead is less than 8 in (15-20 cm), then the back extensors
are considered short (Fig
8).23
Lewit24
says that this test may be invalidated because a patient with a short
trunk and long thighs may give a false-negative result, whereas if the
patient has a long trunk and short thighs there may appear a
false-positive result. Some only consider the posterior fascia shortened
if the iliac crests move anteriorly almost immediately after the patient
flexes rather than waiting for iliac movement before the head is 8 in
from the thighs.23
Lewit24
prefers a test where a seated patient fixes his/her pelvis by placing
the hands on the iliac crests and flexes (“humps”)his/her lumbar spine.
If the lumbar erector spinae are shortened, no lumbar kyphosis is
created (Fig
9).
| Fig 8.
Flexion test to determine restriction of the
posterior fascia. Practitioner's hands on the iliac crest should
not move until the patient's head reaches 8 in from his thigh.
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| Fig 9.
Hump test: patient attempts to create a local
lumbar kyphosis while holding down the iliac crests. Failure to
create a kyphosis indicates restricted posterior lumbar fascia.
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The GT is a patented
instrument-assisted soft tissue mobilization diagnostic and therapeutic
technique developed approximately 10 years ago. The Graston instruments
are made from stainless steel designed with a unique curvilinear edge,
contoured to fit various shapes on the body. These instruments were
developed as an alternative to transverse friction massage. The
rationale for using the GT is based upon the rationale for using manual
soft tissue mobilization as proposed by Cyriax.25
Cyriax used deep friction massage to affect soft tissues.
According to Norris,26
the purpose of frictional massage is to promote a local hyperemia,
massage analgesia, and reduction of scar tissue. In addition, it has
been hypothesized that frictional massage may facilitate tendon healing
by augmenting the inflammatory process to completion so the late stages
of healing can occur.27
Further support for this theory was demonstrated by Davidson28
who found that soft tissue mobilization using Graston procedures
significantly promotes increased fibroblast recruitment. Gehlsen27
also found that application of heavy pressure using Graston instruments
promoted the healing process as measured by fibroblast response to a
greater degree than light or moderate pressure. Treatment components
using the GT also include pretreatment warming of the area and also
emphasize the importance of posttreatment passive and active stretching
exercises targeting the restricted tissues.
The GT plus stretching of the
involved areas is promising in the treatment of subacute lumbar
compartment syndromes. The GT provides a controlled microtrauma to the
involved areas. It is possible that the stainless steel instruments used
in the GT enhance the palpatory skill of the practitioner as he/she
glides them over the surface of the patient's superficial and deep
fascia. The instruments may also provide a mechanical advantage to the
clinician, allowing deeper penetration and possibly greater specificity.
Often, the area becomes hyperemic with petechiae formation. This
reaction represents the stimulation of a local inflammatory response
which can lead to remodeling and repair of the area. It is accepted that
fibroblastic stimulation and an inflammatory reaction, cytoskeletal
remodeling, altered ion transport, and diminishing of cell-matrix
adhesions occurs with mechanical loading on soft tissue.28-32
It appears that the formation of fibroblasts by mechanical load is the
main effect as the repair and maintenance of connective tissues are
performed predominately by the mesenchymal cell, the fibroblast.33
Posttreatment stretching and
strengthening are necessary to provide the forces for adaptive
remodeling of new collagen in the affected areas. Toyoda34
found that chondrocytes when loaded align to the direction of the
tensile load by reconstructing their cytoskeleton. The tensile load also
resulted in an increase in proteoglycan synthesis and collagen synthesis
in the extracellular matrix.
This case
describes the treatment of a patient with subacute lumbar compartment
syndrome using the GT. Previous descriptions of treatment for this
syndrome involve surgical intervention to normalize intramuscular
pressures. In this case study, it is hypothesized that intramuscular
pressures were normalized after instrument-assisted soft tissue
mobilization and stretching. Future prospective research is needed to
quantify lumbar compartmental pressures before and after intervention.
The authors thank Sarah B. Kucera for her assistance with this
project.
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