OMT for Chronic Low Back Pain: OSTEOPATHIC Trial Protocol. Learning Objectives. Chronic Low Back Pain 8/5/2016

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1 OMT for Chronic Low Back Pain: OSTEOPATHIC Trial Protocol David C. Mason, DO, MBA, FACOFP Chair Family Medicine and Osteopathic Manipulative Medicine Texas College of Osteopathic Medicine Learning Objectives Discuss common causes of chronic low back pain Demonstrate focus osteopathic screening exam for patients presenting with chronic low back pain Review and apply the OMT used to treat chronic low back pain from the OSTEOPATHIC Trial Chronic Low Back Pain Greater than 3 months Daily pain in low back History and physical to rule out RED FLAGS 1

2 Psoas Hypertonicity R L David C. Mason, DO, MBA, FACOFP 8/5/2016 Common Somatic Dysfunctions Related to Chronic Low Back Pain Phil Greenman Dirty Half Dozen Non-Neutral Lumbar SD Pubic Shear Innominate Shear Restricted Sacral Nutation Muscle Imbalance Syndrome (Psoas) * Un-level sacral base (LLI) *not in OSTEOPATHIC TRIAL Greenman, PE Syndromes of the lumbar spine, pelvis and sacrum Phys Med Rehabil Clin N Am 1996: Focused Physical Exam Seated Lumber Screen and Triplaner DX Seated Flexion Supine Leg length External hip rotation ASIS compression test ASIS position Pubic symphysis position Iliopsoas tenderpoint Prone PSIS position Sacral base position/sacral sulcus depth ILA postion Ischial tuberosity position Lumbar DX Psoas hypertonicity 5 minute biomechanical evaluation for LBP Documentation of findings a. Patient Supine. b. Reset Pelvis c. Check Leg lengths. d. Check for restriction to internal rotation (piriformis spasm) e. ASIS Compression Test. f. Compare right vs. left ASIS for height and distance from midline. g. Patient Prone. h. Compare right vs. left PSIS for height and distance form midline. i. Check sacral sulci. j. Check ILA. k. Examine Lumbar spine. l. Check for psoas hypertonicity by hip extension. m. Document Lower extremity, Lumbar, Innominate and Sacral diagnoses Standing Flexion Test: R L Seated Flexion Test: R L Supine Exam: Leg Length(Medial Malleoli) Long/Short R L Internal Rotation test (Tight Hip)(piriformis) R L Piriformis Hypertonicity R L ASIS Compression Test: R L ASIS Landmarks Height Cephalad/Caudad R L Prone Exam: Inflare/Outflare R L Lumbar positional DX PSIS Landmarks Cephalad/Caudad R L Inflare/Outflare R L Innominate Positional Diagnosis Sacral Landmarks Sacral Sulcus Deep/Shallow R L ILA Anterior/Posterior R L Inferior R L Sacral Positional Diagnosis 2

3 Seated - Lumber Screen and Triplaner DX - Seated Flexion Supine Leg length External hip rotation ASIS compression test ASIS position Pubic symphysis position Iliopsoas tenderpoints Reset Pelvis 3

Optional to Standing and Seated flexion. Patient Supine, Reset pelvis.

4 Check Leg Lengths and Restriction of Internal Rotation ASIS Compression test Lateralizing test for Sacroiliac joint. Optional to Standing and Seated flexion. Patient Supine, Reset pelvis. AP compression to level of SI joint. Restricted motion is positive test. ASIS Compression 4

5 Check ASIS Height and Symmetry from midline Pubic symphysis position Iliopsoas tenderpoints Prone PSIS position Sacral base position /Sacral sulcus depth ILA postion Ischial tuberosity position Lumbar DX Iliopsoas hypertonicity 5

6 Treatment Techniques Lumbar Innominate Pubes Sacrum Lower Extremity Lumbar (Non-Neutral) Seated Muscle Energy Lateral recumbent Muscle Energy Lateral recumbent HVLA Seated Lumbar MET 6

7 Pubic Dysfunction Supine MET Gap Pubes Supine MET Inferior Shear Supine MET Superior Shear (1) (2) Muscle Energy Gapping of Pubic Symphasis (3) 7

8 MET for Superior Pubic Shear on Left MET for Superior Pubic Shear on Right MET for Inferior Pubic Shear on Right 8

(1) (2) Closing Pubic Symphasis with Muscle Energy HVLA leg tug Innominate Shear ME Respiratory Assist Superior Innominate Shear (Leg Tug) Patient supine.

9 (1) (2) Closing Pubic Symphasis with Muscle Energy HVLA leg tug Innominate Shear ME Respiratory Assist Superior Innominate Shear (Leg Tug) Patient supine. Physician at foot end of table grasps ankle of dysfunction side raises 6-10 inches off of table internally rotates hip joint and applies traction force along leg. Patient inhales and exhales deeply five to seven times. May Add Tug: On last exhalation patient is asked to cough and physician tugs on leg simultaneously. 9

10 Sacrum Lateral Recumbent Posterior Sacral Torsion Prone MET (respiratory assist) Unilateral Extended Sacrum SD Prone MET (respiratory assist) Bilateral Extended Sacrum SD MET ROL Sacral Torsion 10

11 Unilateral Extension Bilateral Extension Lower Extremity Prone Iliopsoas MET Stretch Supine Piriformis MET Stretch 11

Muscle Energy Treatment of Iliopsoas Patient prone leg is lifted and adducted to point of movement of thoracolumbar junction Patient is asked to contract hip flexors to try to bring leg back to

Piriformis Muscle Energy Patient supine Leg is flexed at the knee and hip foot is place either medially or lateral to the opposite knee Operator pushes medially on knee while patient attempts

12 Muscle Energy Treatment of Iliopsoas Patient prone leg is lifted and adducted to point of movement of thoracolumbar junction Patient is asked to contract hip flexors to try to bring leg back to table. Isometric contraction 3-5 seconds. After a second take to knew extension barrier. Repeat 3-5 times Final passive stretch. Piriformis Muscle Energy Patient supine Leg is flexed at the knee and hip foot is place either medially or lateral to the opposite knee Operator pushes medially on knee while patient attempts external rotation of hip Treat any other dysfunctions you think are contributing to CLBP OSTEOPATHIC Trial treated up to 5 additional dysfunctions Innominate SD (Rotation SD, Flair SD) Neutral Lumbar SD Anterior Sacral SD (Torsions, Uni Flexions) LE SD (Piriformis, Hamstring) 12

13 Stretching Piriformis Iliopsoas Hamstrings Strengthening Gluteus Quads Home exercises 13

Information within the handout. Brief Introduction Anatomy & Biomechanics Assessment & Diagnosis Treatment through Muscle Energy

Information within the handout. Brief Introduction Anatomy & Biomechanics Assessment & Diagnosis Treatment through Muscle Energy Manual Medicine Diagnosis and Treatment for Somatic Dysfunction of the Pelvis Through Muscle Energy Greenman s Priciples of Manual Medicine (5 th Ed.)- Lisa DeStefano,DO Speaker disclosure I declare I