The Role of the Abdominal Muscles in Lumbar and Abdominopelvic Dysfunction

Featured Speaker: Brian Lau, AP, CSMA

I will be presenting on the role of the abdominal muscles in lumbar and abdominopelvic pain. While these muscles can form painful trigger points (TrPs) which can be the chief complaint, they are often players in a more segmental dysfunction occurring at the thoracolumbar region and affecting other muscles and even internal dysfunction of the abdominopelvic organs. The following is a case study which is indicative of how these abdominal muscles can be involved in the greater clinical picture.

Female, 39, with chief complaint of low back pain around the left sacroiliac joint (SIJ) region with radiation to the pelvis, especially wrapping around towards GB 29. Pain is chronic and has been present for about 10 years and worsening over the last 2-4 years with occasional episodes of acute spasm which can make day to day function difficult. Pain is not constant, but can be 8/10 when it flares. Pain feels fixed and deep at the PSIS and iliac crest region and can send a strong ache deep in the pelvis to the anterolateral side of the pelvis. Patient feels that sitting at her desk aggravates her pain, particularly if she is slouching. Patient is training for a triathlon, and recently, bicycling aggravates the condition. Swimming sometimes helps loosen and alleviate the pain, as does stretching arms overhead or hanging from a bar. Patient is a Pilates practitioner and this has recently started aggravating the pain along with other abdominal training. Sleeping aggravates the condition, especially when lying on the left side.

Patient has a history of menstrual pain, abdominal distention, and a relatively strong flow for 4 days. She has some general abdominal distention with occasional constipation and difficulty voiding; she also has frequent muscle tension headaches.

Patient has a negative SIJ Rocking Test and SIJ shear test on the left. The Gillet test is negative bilaterally. The Yeoman test is negative. The pelvis is bilaterally anterior tilted with a greater amount on the left side. The pelvis is slightly left rotated and slightly left elevated, but the pelvis overall has a pronounced anterior tilt. The ribcage is posteriorly tilted and there is compression at the thoracolumbar region of the spine. The ribcage is right rotated in relation to the pelvis.

Palpation reveals pain and taut bands in the lumbar multifidi in the SIJ region into the L5 region which feels associated with the pain. Taut bands in the quadratus lumborum are particularly pronounced on the left side and this is most pronounced when pressing towards the medial part of the muscle. There is a pronounced anteriority at the thoracolumbar region and P-A (Posterior to Anterior) mobilization; also, deep palpation in the thoracolumbar transversospinalis muscles on the left sends a deep ache to the pelvis and ASIS region on the left and also into the SIJ region. There is pain with palpation at the lateral raphe on the R side, which has more soreness than the patient expected.

Palpation of the abdomen is what is particularly relevant for the class I will be teaching in August. There are multiple regions of taut bands and trigger points in the rectus abdominis and related fascial structures.

There is sensitivity at the lateral border of the rectus abdominis at the semilunar line along the Spleen channel and there is also sensitivity with palpation into the belly of the rectus abdominis at the Stomach channel. This was most notable at the region of the motor point around ST 27. However, deep palpation of the rectus abdominis along the left KID channel around KID 14 revealed taut bands in the medial aspect of the muscle and also a strong density when directing the palpation from the KID channel towards the lineal alba. Both of these vectors, but particularly the medial edge of the rectus abdominis recreated some of the pain the patient experiences during menstruation, but also referred deep into the SIJ region on the L side.

Treatment included acupuncture in a prone position: needling the deep, medial fibers of the QL around L2 (needle directed from the lateral border of the QL, into the muscle and towards the attachments at the L2 transverse processes); the lateral raphe at L2 on the right; huatuojiaji points bilateral at T11-L2 to the depth of the transversospinalis muscle group; multifidi at the region of the SIJ on the left; LU 7, KID 3 and UB 58 (UB 58 has a slight radiation to the SIJ on the L); lower trapezius and upper trapezius trigger points.

The needles were retained for 10 minutes, removed and the patient was turned over to a supine position. Trigger point needling was performed on the rectus abdominis TrPs along the KID channel. The needle depth was to the posterior rectus sheath immediately deep to the rectus abdominis.

Multiple fasciculations were evoked on the left side and the sensation referred deep into the pelvis and into the left SIJ. TrPs were located in the tibialis anterior in the region of ST 36 on the left and also treated. 

The patient was taught a qigong exercise focusing on abdominal and spinal movement. Upon return visit the following week, the patient had almost no pain for several days followed by a return of some of the pain. Overall, she still retained a 50% reduction of pain. The patient had weekly treatments for 3 more times and the pain had mostly subsided. The pain during menstruation was also notably diminished and we will continue to monitor this.

The overall treatment involved related neuromyofascial tissue. There is a strong fascial connection between the quadratus lumborum and the rectus abdominis which travels through the fascial layers of the internal oblique and transverse abdominis, connects with the lateral raphe and continues into the 2 layers of the thoracolumbar fascia in the lumbar region. The structures that were dysfunctional came from the spinal segments T11-L2. 

This included innervation to the quadratus lumborum and rectus abdominis, but this is also a region where the cutaneous cluneal nerves arise before exiting at the iliac crest region and draping over the SIJ region and lateral to the SIJ. There are also cutaneous branches of the lumbar plexus nerves which travel to the ASIS region of the hip. This spinal segment also includes innervation to the kidneys, adrenal glands, and digestive organs. When this region is sensitized, multiple dysfunctions can be observed at this sensitized spinal segment, accounting for much of the symptomology. Treatment to as many of these sensitized structures as possible yields longer lasting results and the abdominal muscles can be a key element in many lumbar and abdominopelvic issues.

Brian Lau, AP, CSMA his certified in Sports Medicine Acupuncture, and Structural Integration. He has been on faculty since 2013 with the Sports Medicine Acupuncture Certification (SMAC) program, where he teaches anatomy, palpation, assessment and treatment of the channel sinews (jingjin), acupuncture, and myofascial release techniques. Brian leads regular 1-5 day cadaver dissections for acupuncturists in many venues and also for physician assistance students at the University of Tampa. He also teaches anatomy and physiology at Dragon Rises College of Oriental Medicine in Bradenton, FL.

His main focus is on integrating Western anatomical information with the Chinese medical channel system and he has developed an anatomical model of the channel system which he applies to acupuncture, manual therapy, and movement. Brian is also a veteran taiji and qigong instructor. He owns and operates Ideal Balance Center for Acupuncture and Sports Medicine in Tampa, Florida, and teaches channel-based functional movement in live classes, on Zoom, and via his YouTube channel, Jingjin Movement Training.