OMT Boot Camp. OMT Applications for Systemic Somatic Dysfunctions of the Spine. Natalie Nevins, DO, MSHPE

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1 ACOFP 54 th Annual Convention & Scientific Seminars OMT Boot Camp OMT Applications for Systemic Somatic Dysfunctions of the Spine Natalie Nevins, DO, MSHPE

Lumbar, Innominate, Sacrum Diagnosis and Treatment Review Natalie A.

Western University of Health Sciences College of Os

for assisting with the enclosed slides Passive Range of Motion (PROM): Segmental Vertebral Diagnosis Evaluation can be done in

Once identified test for changes when the patient extends the segment. If the asymmetry worsens this segment is in FLEXION.

3 Lumbar, Innominate, Sacrum Diagnosis and Treatment Review Natalie A. Nevins, DO, MSHPE Director of Clinical Education Clinical Professor of NMM/OMM Clinical Associate Professor of Family Practice Western University of Health Sciences College of Osteopathic Medicine of the Pacific Special thank you to Elias J. Ptak, D.O. for assisting with the enclosed slides Passive Range of Motion (PROM): Segmental Vertebral Diagnosis Evaluation can be done in either the seated or prone positions Palpate for posterior transverse processes. Once identified test for changes when the patient extends the segment. If the asymmetry worsens this segment is in FLEXION. If the asymmetry improves this segment is in EXTENSION. If it does not change this segment is NEUTRAL If the diagnosis is not clear with only testing extension, flexion can be tested in the seated position to confirm your findings. Test Neutral Prone Test Extension in Prone Prop Test Flexion Seated DeStefano LA, Greenman s principles of manual medicine, 4th ed,

4 Innominate Diagnosis: Standing Flexion Test Identifies the side of iliosacral somatic dysfunction (motion of ilium on the sacrum). 1. Have the patient stand in front of you with their feet at shoulders width apart. Also have your eyes at the level of the patient s PSISs or a few inches above. 2. Hook your thumbs underneath the patient s PSIS bilaterally, and rest your fingers comfortably on the iliac crests or gluteal muscles. 3. Ask the patient to bend forward slowly while your thumbs follow the movement of the PSIS. Positive Test: Innominate Diagnosis: Standing Flexion Test cont. When one PSIS moves superiorly relative to the other during the last 10 degrees of forward bending. The side found to have a positive standing flexion test is referred to as the lateralized side and is the side of iliosacral dysfunction. All Innominate diagnoses are named on the lateralized side of Iliosacral dysfunction. Tight hamstrings on the contralateral side can cause a False Positive. 2

Innominate Diagnosis: ASIS Heights This is done in order to

With patient supine, use your entire palms to locate the ASISs.

one is superior or inferior to the other.

determine if one pubic ramus is superior or inferior.

beginning With the patient supine, place one palm on the abdomen

5 Innominate Diagnosis: ASIS Heights This is done in order to determine if one ASIS is superior or inferior. With patient supine, use your entire palms to locate the ASISs. Hook your thumbs horizontally under each ASIS and compare which one is superior or inferior to the other. The side of the positive standing flexion test is the side of concern. Innominate Diagnosis: Pubic Ramus Heights This is done to determine if one pubic ramus is superior or inferior. Tell the patient exactly what you are going to do before beginning With the patient supine, place one palm on the abdomen and moves caudally until you contact the superior aspect of the pubic rami. Now place your index fingers superiorly on each pubic rami. By looking straight down your fingers, compare their heights 3

Innominate Diagnosis: Supine Leg Length This is done to determine

at the end of the table and with your thumbs palpate the most

Rotation = Short Leg *As a general rule: The MEDIAL MALLEOLUS WILL

Setting the pelvis takes out postural myofascial patterning.

6 Innominate Diagnosis: Supine Leg Length This is done to determine if there are leg length differences in the supine position: Stand at the end of the table and with your thumbs palpate the most inferior aspect of each medial malleolus, determining if one leg is longer or shorter than the other. Unequal findings may be the results of an anatomic or functional leg length asymmetry. Functional Asymmetry Anterior Rotation = Long Leg Posterior Rotation = Short Leg *As a general rule: The MEDIAL MALLEOLUS WILL FOLLOW THE ASIS* Innominate Diagnosis: Set the Prone Pelvis Setting the pelvis takes out postural myofascial patterning. This neutralizes (re-seats) the pelvis for more consistent pelvic diagnosis. Physician passively and slowly bends patient s knees then returns the legs to the table. 4

Innominate Diagnosis: PSIS Heights This is done to determine if one

With patient prone, use palms to locate the PSISs.

Innominate Diagnosis: Ischial Tuberosity Heights This is done to

Tell the patient exactly what you are going to do before beginning.

slightly medially, to locate the ischial tuberosities, then place your

7 Innominate Diagnosis: PSIS Heights This is done to determine if one PSIS is superior or inferior. With patient prone, use palms to locate the PSISs. Hook your thumbs horizontally under each PSIS and compare which one is superior or inferior to the other. The side of the positive standing flexion test is the side of concern. Innominate Diagnosis: Ischial Tuberosity Heights This is done to determine if one ischial tuberosity is superior or inferior. Tell the patient exactly what you are going to do before beginning. With the patient prone, place your palms into the gluteal fold, slightly medially, to locate the ischial tuberosities, then place your thumbs horizontal on the tuberosities and compare the heights. The side of the positive standing flexion test is the side of concern. *As a general rule: THE ISCHIAL TUBEROSITY WILL FOLLOW THE PSIS* 5

8 Fryette Mechanics Type I Motion/Somatic Dysfunction (Neutral) Neutral somatic dysfunctions of the thoracic or lumbar spine: sidebending and rotation in a group occur in opposite directions. When treating group dysfunctions the APEX of the group is the focus of the treatment Type II Motion/Somatic Dysfunction (Non-neutral) Non-neutral somatic dysfunctions of the thoracic or lumbar spine (either flexed or extended) occur at a single vertebral unit: sidebending and rotation occur in the same directions Muscle Energy: Lumbar NSR- L2-4 NS L R R The patient is seated and you stand on the side opposite the rotational component of the segmental dysfunction. The patient places his left hand over the right shoulder. Your left arm weaves under the patient s left arm and your hand is placed over the patient s left hand to control his right shoulder. Place your right thumb at the apex of the right convexity (L3 in this case) and apply a force vector in an anteromedial direction. 6

The patient performs an isometric contraction attempting to side bend to the left against your counterforce for 3-5 seconds.

9 Muscle Energy: Lumbar NSR- L2-4 NS L R R cont. While maintaining the spine in neutral, the trunk is side bent to the right and the upper trunk rotated to the left until movement is felt at the L3 segment. The patient performs an isometric contraction attempting to side bend to the left against your counterforce for 3-5 seconds. The patient then relaxes and slack is taken-up until the next restrictive barriers are engaged. This contraction, relaxation, and barrier re-engagement cycle is repeated up to 3 times until adequate improvement in motion is obtained. Muscle Energy: Lumbar FRS- L4 FR L S L The patient is seated and you stand or sit behind the patient. With the left hand, monitor the interspinous region between L4 and L5 and the transverse processes of L4. Bring the patient s upper trunk into extension, right side bending, and right rotation to the L4 segment. 7

Muscle Energy: Lumbar ERS- L4 ER R S R The patient is seated and you are standing in front of the patient. Ask the patient to place his left hand on his right shoulder.

10 Muscle Energy: Lumbar ERS- L4 ER R S R The patient is seated and you are standing in front of the patient. Ask the patient to place his left hand on his right shoulder. Place your left axilla over the patient s left shoulder and your hand over his left hand to control his right shoulder. With your right hand, monitor the interspinous region between L4 and L5 and the transverse processes of L4. Bring the patient s upper trunk into flexion, left side bending, and left rotation to the L4 segment. Muscle Energy: Lumbar ERS- L4 ER R S R cont. The patient performs an isometric contraction attempting to side bend to the right against your counterforce for 3 to 5 seconds. The patient then relaxes and slack is taken-up until the next flexion, left side bending and left rotation restrictive barriers are engaged. This contraction, relaxation, and barrier re-engagement cycle is repeated up to 3 times until adequate improvement in motion is obtained. 8

Counterstrain Evaluate tenderpoints Chose the most tender in a group Ask the patient to rate the pain 1-10 Position the patient for treatment Re-evaluate pain level for

11 Counterstrain Evaluate tenderpoints Chose the most tender in a group Ask the patient to rate the pain 1-10 Position the patient for treatment Re-evaluate pain level for at least a 2/3 improvement Hold position for 90 sec (ribs 120 sec) Return to resting position Re-evaluate pain level Anterior Lumbar Counterstrain AL1 AL3 AL2 AL4 AL5 9

Anterior Lumbar Counterstrain: AL1 Counterstrain point location The anterior L1 counterstrain point is found by pressing in a lateral direction on the medial aspect of the ASIS of the ilium.

, RennieMatrix Treatment position Flexion of the hips and lumbar spine to the L1 level with trunk rotation away (pelvic rotation toward) the tender side and side bending toward by pulling the feet

12 Anterior Lumbar Counterstrain: AL1 Counterstrain point location The anterior L1 counterstrain point is found by pressing in a lateral direction on the medial aspect of the ASIS of the ilium. From Counterstrain and Exercise: An Integrated Approach, 3 rd ed., RennieMatrix Treatment position Flexion of the hips and lumbar spine to the L1 level with trunk rotation away (pelvic rotation toward) the tender side and side bending toward by pulling the feet toward tender point side. Anterior Lumbar Counterstrain: AL2 Counterstrain point location The anterior L2 counterstrain point is found at the inferior and medial aspect of the AIIS. Treatment position Flexion of the hips and lumbar spine to the L2 level with trunk rotation toward (pelvic rotation away) from the tender side and side bending away by pulling the feet away from the tender point side. From Counterstrain and Exercise: An Integrated Approach, 3 rd ed., RennieMatrix 10

Anterior Lumbar Counterstrain: AL3 & AL4 Counterstrain point location The anterior L3 point is at the lateral portion of the AIIS while the anterior L4 point is at the inferior portion of the AIIS.

, RennieMatrix Treatment position Flexion of the hips and lumbar spine to either the L3 or L4 level (depending on which tender point is being treated) with trunk rotation toward (pelvic rotation

13 Anterior Lumbar Counterstrain: AL3 & AL4 Counterstrain point location The anterior L3 point is at the lateral portion of the AIIS while the anterior L4 point is at the inferior portion of the AIIS. Both points are treated similarly. From Counterstrain and Exercise: An Integrated Approach, 3 rd ed., RennieMatrix Treatment position Flexion of the hips and lumbar spine to either the L3 or L4 level (depending on which tender point is being treated) with trunk rotation toward (pelvic rotation away) from the tender side and side bending away by pulling the feet away from the tender point side. Anterior Lumbar Counterstrain: AL5 Counterstrain point location The anterior L5 counterstrain point is found on the anterior, superior aspect of the pubic rami just lateral from the symphysis. Treatment position Flexion of the hips to the L5 level with trunk rotation away (pelvic rotation toward) the tender side and side bending away by moving the feet away from the tender point side. Knees should be essentially over (anterior) to the tender point. From Counterstrain and Exercise: An Integrated Approach, 3 rd ed., RennieMatrix 11

Posterior Lumbar Counterstrain Left side: PL1-5 Right side: PL1-5 Posterior Counterstrain: PL1-5 Counterstrain point location At the inferolateral

From Counterstrain and Exercise: An Integrated Approach, 3 rd ed.

14 Posterior Lumbar Counterstrain Left side: PL1-5 Right side: PL1-5 Posterior Counterstrain: PL1-5 Counterstrain point location At the inferolateral side of the deviated spinous process. This signifies vertebral rotation of this segment to the opposite direction. From Counterstrain and Exercise: An Integrated Approach, 3 rd ed., RennieMatrix Treatment position Extend the lower trunk on the ipsilateral side of the deviated spinous process by lifting the pelvis in a posterior direction. This creates extension and relative rotation of the upper trunk away from the tender point side. 12

15 Pelvic Counterstrain High Ilium Piriformis Lateral Trochanter Gluteus Medius Coccygeus Iliacus Piriformis Counterstrain Point Tender point location Treatment position Found half way along a line Marked flexion of the hip with between the top of the greater abduction and fine-tuning with either trochanter and a point internal or external rotation. between the PSIS and the coccyx. Flex Abd Extrn or intrn 13

Iliacus Counterstrain Point Tender point location 1/3 distance from the ASIS to the

Treatment position Marked bilateral flexion and external rotation of the hips with the

Lateral Trochanter Counterstrain Point Tender point location Found about 12 cm below the

16 Iliacus Counterstrain Point Tender point location 1/3 distance from the ASIS to the midline of the abdomen pressing deep in a postero-lateral direction toward the iliacus. Treatment position Marked bilateral flexion and external rotation of the hips with the knees flexed. FLEXternal rot. Lateral Trochanter Counterstrain Point Tender point location Found about 12 cm below the greater trochanter along the lateral surface of the trochanter. Treatment position Moderate abduction of the thigh with slight flexion. Abduct...flex 14

17 Physiologic Somatic Dysfunctions: Innominate Rotations PSIS ASIS ASIS PSIS Anterior Innominate Rotation: This will result in a relatively longer leg on the same side Posterior Innominate Rotation: This will result in a relatively shorter leg on the same side Non-Physiologic Somatic Dysfunctions: Innominate Shears PSIS ASIS PSIS ASIS Superior Innominate Shear Inferior Innominate Shear 15

ME for Anterior Innominate Rotation Steps: 1. Patient is supine with the physician standing on the opposite side of the dysfunction with the hip and knee flexed. 2.

With his lower hand, the physician places the heel of the hand on the ischial tuberosity and exerts a cephalad and lateral force on the ischial tuberosity while the physician

Physician Force Blue, Patient Force Red ME for Posterior Innominate Rotation Steps: 1.

The patient s leg is placed between the physician s knees while the pelvis is supported with a hand placed over the contralateral innominate.

18 ME for Anterior Innominate Rotation Steps: 1. Patient is supine with the physician standing on the opposite side of the dysfunction with the hip and knee flexed. 2. With his upper hand, the physician flexes, externally rotates, and abducts patient s right leg, which loose packs the right sacroiliac joint 3. With his lower hand, the physician places the heel of the hand on the ischial tuberosity and exerts a cephalad and lateral force on the ischial tuberosity while the physician resists extension of the leg by the patient for 3 to 5 reps. Slack is taken up between the contraction intervals then the innominate is reassessed. Physician Force Blue, Patient Force Red ME for Posterior Innominate Rotation Steps: 1. The physician stands on the side of dysfunction and brings the supine patient s SI joint to the edge of the table. 2. The patient s leg is placed between the physician s knees while the pelvis is supported with a hand placed over the contralateral innominate. Tip: Variations in leg placement are possible as long as the patient s leg is comfortable. 3. Physician s other hand applies a force to the floor which attempts to pull the ipsilateral innominate toward anterior rotation. 4. The physician resists as the patient flexes the hip for 3 to 5 reps. Slack is taken up between the contraction intervals then the innominate is reassessed. Physician Force Blue, Patient Force Red 16

ME for Superior or Inferior Pubic Shear Steps: 1. Patient is supine with the hips and knees flexed and feet together and flat on the table. 2.

seconds or until a release is felt at the pubic symphysis. Note: During this step, a "pop" sound may occur. The noise is completely benign. 4.

Patient Abducts Knees Patient Adducts Knees Physician Force Blue, Patient Force Red Sacroiliac Joint BLT Physician sits on the same side as the SI somatic

19 ME for Superior or Inferior Pubic Shear Steps: 1. Patient is supine with the hips and knees flexed and feet together and flat on the table. 2. Physician first holds the patient s knees together and resists as the patient attempts to abduct both knees for one rep of 3 to 5 seconds. 3. The physician then holds (or places the forearm between) the patient s knees and resists as the patient attempts to adduct both knees for one rep of 3 to 5 seconds or until a release is felt at the pubic symphysis. Note: During this step, a "pop" sound may occur. The noise is completely benign. 4. Assess that proper release was obtained. Patient Abducts Knees Patient Adducts Knees Physician Force Blue, Patient Force Red Sacroiliac Joint BLT Physician sits on the same side as the SI somatic dysfunction The posterior hand contacts the posterior aspect of the sacrum, as close to the SI joint as possible The more proximal part of the fingers of this hand also contact the medial aspect of the PSIS The other hand is placed on the ASIS. The ASIS will be your handle on the innominate (hip) bone With the posterior hand place a slight anterior force on the sacral sulcus with your finger pads and a lateral force on the PSIS with the more proximal portion of the fingers to disengage the SI joint 17

the innominate to create balance at he sacroiliac ligaments (in anterior/posterior rotation, inflare/outflare

20 Sacroiliac Joint BLT cont. While maintaining the disengagement with the slight anterior and lateral force from your posterior hand, move the innominate to create balance at he sacroiliac ligaments (in anterior/posterior rotation, inflare/outflare and superior/inferior shear). Remember, these are minor motions. Establish a point of balanced ligamentous tension, hold until a release is felt and then retest. Sacral Evaluation and Treatment 18

Sacrum Diagnosis: Seated Flexion Test Positive Test (+SeFT): When one PSIS moves superiorly relative to the other during

This has identifies which side of the sacrum is dysfunctional.

If the patient bends too far forward it can cause a False Positive by one ischial tuberosity rising off the table.

Sacral Anatomical Landmarks Sacral Sulcus: A depression (an area) just medial to the PSIS as a result of the spatial

In osteopathic palpation, the uppermost posterior portion of the sacrum. (FOM Glossary) 2.

21 Sacrum Diagnosis: Seated Flexion Test Positive Test (+SeFT): When one PSIS moves superiorly relative to the other during the last 10 degrees of forward bending and is referred to as the positive side. This has identifies which side of the sacrum is dysfunctional. All sacral diagnoses are named on the lateralized side of sacroiliac dysfunction. If the patient bends too far forward it can cause a False Positive by one ischial tuberosity rising off the table. Make sure each tuberosities do not come off the table. Sacral Anatomical Landmarks Sacral Sulcus: A depression (an area) just medial to the PSIS as a result of the spatial relationship of the PSIS to the dorsal aspect of the sacrum. (FOM Glossary) Sacral Base: 1. In osteopathic palpation, the uppermost posterior portion of the sacrum. (FOM Glossary) 2. The most cephalad portion of the first sacral segment. (Gray s Anatomy) Inferior Lateral Angle (ILA): The point on the lateral surface of the sacrum where it curves medially to the body of the fifth sacral vertebrae. (Gray s Anatomy) Sacral Sulcus area ILA area Sacral Base ILA Anterior or Posterior ILA Superior or Inferior Thieme Atlas of Anatomy; General Anatomy and Musculoskeletal System, 1st ed,

Lumbosacral Spring Test This is a test for permitted motion at the lumbosacral junction With the patient prone, place the heel of the hand over the lumbosacral junction and apply a short, anterior

22 Lumbosacral Spring Test This is a test for permitted motion at the lumbosacral junction With the patient prone, place the heel of the hand over the lumbosacral junction and apply a short, anterior force multiple times to test for permitted motion or spring. This is fundamentally testing PASSIVE RANGE OF MOTION of the sacral base, evaluating for sacral flexion. Force Anteriorly at the Lumbosacral Junction DeStefano LA, Greenman s principles of manual medicine, 4th ed, 2011 Positive Test: Lumbosacral Spring Test cont. If the sacrum is held backward (extended) you will feel restricted motion (i.e. poor spring) and the test is recorded as positive. Sacroiliac dysfunctions that have part or all of the sacral base rotated posteriorly will have poor spring. Negative Test: (+) Test, Poor Spring: backward torsions, bilateral extensions and unilateral extensions Conversely, if the sacrum is held forward (flexed) you will feel no restricted motion (i.e. Good Spring) and the test is recorded as negative. Sacroiliac dysfunctions that have part or all of the sacral base rotated anteriorly will have good spring. ( )Test, Good Spring: forward torsions, bilateral flexion and unilateral flexion Note: In some board questions and texts this test is classically called just Spring Test. Thieme Atlas of Anatomy; General Anatomy and Musculoskeletal System, 1st ed,

ILA Spring Test: This tests for the motion of the sacrum as induced from the ILAs (sacral apex).

over the ILAs (sacral apex) and apply a short, anterior force multiple times to test for permitted motion or spring.

(-)Negative test: This is found to have GOOD spring and occurs with bilateral and unilateral extensions and backward torsions Force Anteriorly at the ILAs Thieme

base to move anteriorly (flexion aka nutation) by extending the lumbar spine.

23 ILA Spring Test: This tests for the motion of the sacrum as induced from the ILAs (sacral apex). Anterior force imposed at the apex is testing passive range of motion of the sacral base for sacral extension With the patient prone, place the heel of the hand over the ILAs (sacral apex) and apply a short, anterior force multiple times to test for permitted motion or spring. L5 (+)Positive test: This is found to have POOR spring and occurs with; bilateral and unilateral flexions, and forward torsions. (-)Negative test: This is found to have GOOD spring and occurs with bilateral and unilateral extensions and backward torsions Force Anteriorly at the ILAs Thieme Atlas of Anatomy; General Anatomy and Musculoskeletal System, 1st ed, 2010 Backward Bending Test The purpose of this test is to evaluate the ability for the sacral base to move anteriorly (flexion aka nutation) by extending the lumbar spine. This is ACTIVE RANGE OF MOTION of he sacral base that you are monitoring for improving or worsening symmetry. Place your thumbs in the sacral sulcus and determine which one is deep and which one is shallow. Have the patient prop up on her elbows and examine the sacral sulcus depths(and ILA s) in this position. Note: This takes the sacral base anterior into flexion as the lumbar spine is extended. 21

Backward Bending Test cont. Positive Test: If the sacrum is held backward (extended) you will feel the asymmetry worsen between each sulcus (and the ILA s ), the test is recorded as positive.

24 Backward Bending Test cont. Positive Test: If the sacrum is held backward (extended) you will feel the asymmetry worsen between each sulcus (and the ILA s ), the test is recorded as positive. Sacroiliac dysfunctions that have part of the sacral base rotated posteriorly will have a positive backward bending test. (+) Test, Asymmetry Worsens: backward torsions and unilateral extensions (not bilateral Extensions) Negative Test: Conversely, if the sacrum is held forward (flexed) you will feel the asymmetry improve between each sulcus (and the ILA s) the test is recorded as negative. Sacroiliac dysfunctions that have part of the sacral base rotated anteriorly will have a negative backward bending test. ( )Test, Asymmetry Improves: forward torsions and unilateral flexion (not bilateral Flexion) This test is often referred to as the Sphinx test Sacral Diagnosis Considerations When evaluating a sacrum and finding a Deep (anterior) sulcus on one side and a Posterior/Inferior (shallow) ILA on the OPPOSITE side the diagnosis will be a SACRAL TORSION When evaluating a sacrum and finding a Deep (anterior) sulcus on one side and a Posterior/Inferior (shallow) ILA on the SAME side the diagnosis will be a UNILATERAL SACRAL Flexion or Extension AKA; SHEAR Though this rule can help streamline your diagnostic process, you must be prepared to answer questions when findings such as Shallow or posterior sulcus and Anterior/Superior or deep ILA are provided. 22

25 Sacral Evaluation and Treatment Findings of a deep sulcus and Posterior/Inferior ILA on opposite sides; some kind of TORSION Findings of a deep sulcus and Posterior/Inferior ILA on same sides; UNILATERAL something D S D S A/S P/I P/I A/S Sacral Evaluation and Treatment This could be either a Right on Left Backward sacral torsion OR A Right on Right forward torsion This could be either a Left Unilateral Flexion OR A Right Unilateral Extension D D P/I P/I 23

Bilateral Sacral Flexion ( Flex-In-In ) The seated flexion test will be negative/inconclusive- both sides will move equally The sacral sulci will appear bilaterally anterior (deep) The Inferior

The lumbosacral spring test will be negative; meaning that it will allow anterior motion To treat this we will position the legs/hips bilaterally into internal rotation to open the posterior aspect

26 Bilateral Sacral Flexion ( Flex-In-In ) The seated flexion test will be negative/inconclusive- both sides will move equally The sacral sulci will appear bilaterally anterior (deep) The Inferior Lateral Angles will appear bilaterally posterior/inferior (shallow) The Inferior Lateral Angle Spring test will be positive, meaning that it will resist anterior motion. The lumbosacral spring test will be negative; meaning that it will allow anterior motion To treat this we will position the legs/hips bilaterally into internal rotation to open the posterior aspect and close the anterior aspect of the SI joints bilaterally Inhalation encourages sacral motion into extension(counter-nutation) D =Denotes ANTERIOR or Deep P/I D D P/I P/I = Denotes POSTERIOR/ Inferior or Shallow Muscle Energy: Bilateral Sacral Flexion ME Type: Respiratory Assistance 1. With patient prone, abduct both legs 15 degrees to loose-pack both SI joints. 2. Internally rotate both legs to gap the posterior aspect of both SI joints (this will allow the sacrum to move posterior). 3. Heel of the hand presses anterior-superior on the (posterior/inferior) sacral apex at the midline, encouraging inhalation while resisting exhalation as the patient takes deep breaths. This will help bring the sacral base posteriorly. 4. Repeat for 3-5 cycles then retest. L5 D D Physician Force Blue P/I P/I ( ) Seated flexion test Bilat. Deep Sacral Sulci Bilat. Posterior/Inferior ILA ( ) Lumbosacral Spring Test (+) ILA Spring Test 24

Bilateral Sacral Extension ( Ex-Ex-Ex ) The seated flexion test will be negative/inconclusive= both sides will move equally The sacral sulci will appear bilaterally posterior (shallow) The Inferior

The Inferior Lateral Angle Spring test will be negative; meaning that the sacral base can move into extension.

27 Bilateral Sacral Extension ( Ex-Ex-Ex ) The seated flexion test will be negative/inconclusive= both sides will move equally The sacral sulci will appear bilaterally posterior (shallow) The Inferior Lateral Angles will appear bilaterally anterior/superior (deep) The LUMBOSACRAL Spring Test will be positive, meaning that it will resist anterior motion. The Inferior Lateral Angle Spring test will be negative; meaning that the sacral base can move into extension. To treat this we will position the legs/hips bilaterally into external rotation to open the anterior aspect and close the posterior aspect of the SI joints bilaterally and extend the lumbar spine. Exhalation phase will be encouraged to promote sacral base flexion (nutation) Extension treatment: Extend Lumbar spine, Externally rotate legs, encourage Exhalation phase S =Denotes Posterior or Shallow A/S S A/S S A/S = Denotes Anterior/ Superior or Deep Muscle Energy: Bilateral Sacral Extension ME Type: Respiratory Assistance 1. With patient prone, abduct both legs 15 degrees to loose-pack both SI joints. 2. Externally rotate both legs to gap the anterior aspect of both SI joints (this will allow the sacrum to move anteriorly). 3. The patient is asked to come up on his elbows to achieve the Prone-Prop position. This forces the sacral base anteriorly into its restriction. 4. Heel of the hand presses anterior-inferior on the (shallow) sacral base at the midline, encouraging exhalation while resisting inhalation as the patient takes deep breaths. This will help bring the sacral base anteriorly. L5 5. Repeat for 3-5 cycles then retest. S S Physician Force Blue A/S A/S DeStefanoLA, Greenman s principles of manual medicine, 4th ed, 2011 ( ) Seated flexion test B/L Shallow Sacral Sulci B/L Anterior/Superior ILA (+) Lumbosacral Spring Test ( ) ILA Spring Test 25

MFR- Prone Lumbosacral Release Assess the thoracolumbar myofascial tissues in the following planes: o Rotation (Left/Right,

in opposite directions) o Flexion/Extension (superior/inferior movement of hands) Hold tissues in all planes of ease

Rotation Left Sidebending Left Sidebending Right MFR- Prone Lumbosacral Release Flexion/Extension (superior/inferior

28 MFR- Prone Lumbosacral Release Assess the thoracolumbar myofascial tissues in the following planes: o Rotation (Left/Right, often the hands are moving in opposite directions) o Side Bending (Clockwise/Counterclockwise, often the hands are moving in opposite directions) o Flexion/Extension (superior/inferior movement of hands) Hold tissues in all planes of ease (indirect) or restriction (direct)- this may match what is being done on the sacrum Flexion Extension Rotation Right Rotation Left Sidebending Left Sidebending Right MFR- Prone Lumbosacral Release Flexion/Extension (superior/inferior movement of the hands) Physician Force Blue Physician Force Blue Extension: The hands move together. Neutral Flexion: The hands move apart. 26

MFR- Prone Lumbosacral Release Rotation: Hands move in

relative to the movement of the torso(cephalad hand)

Neutral Rotation Right MFR- Prone Lumbosacral Release

clockwise and counterclockwise, if so, it is named for

If the hands move in the same direction it is named for

29 MFR- Prone Lumbosacral Release Rotation: Hands move in opposite directions left and right, rotation is named relative to the movement of the torso(cephalad hand) Physician Force Blue Physician Force Blue Rotation Left Neutral Rotation Right MFR- Prone Lumbosacral Release Sidebending: The hands can move in opposite directions, clockwise and counterclockwise, if so, it is named for the side of the concavity. If the hands move in the same direction it is named for the cephalad hand Physician Force Blue Sidebending Right Neutral Physician Force Blue Sidebending Left 27

MFR- Prone Lumbosacral Release After assessment of each of the planes of motion, hold the tissues in all planes of ease (indirect) or restriction (direct) until

Have patient hold breath in position of ease if performing indirect or position which tightens the restriction if performing direct.

In this image; If this were indirect treatment the diagnosis would be: flexion, right rotation and left sidebending If this were direct, it would be the opposite

30 MFR- Prone Lumbosacral Release After assessment of each of the planes of motion, hold the tissues in all planes of ease (indirect) or restriction (direct) until release is palpated. Respiratory assistance as an activating force can be utilized. Have patient hold breath in position of ease if performing indirect or position which tightens the restriction if performing direct. This can be done with a single plane of motion at a time or multiple based on patient tolerance and practitioner skill level. In this image; If this were indirect treatment the diagnosis would be: flexion, right rotation and left sidebending If this were direct, it would be the opposite Sacral Rock 1. The patient is prone, and the physician stands at the side of the patient 2. Place the cephalic (palpating) hand on the sacral base with the fingers pointing toward the coccyx Place the caudal (operating) hand on top of the cephalic hand with the fingers pointing toward the opposite direction

Gently spring against the barrier in each direction alternately, repeating several times in a slow rocking motion. 8.

31 Sacral Rock cont. 5. Gently move the sacrum into flexion (nutation) 5. Flexion 4. Neutral 6. Then gently move the sacrum extension (counternutation) 6. Extension While palpating, determine where the greatest restriction is in each phase of motion. Sacral Rock cont. 7. Gently spring against the barrier in each direction alternately, repeating several times in a slow rocking motion. 8. Respiratory assistance can be used additionally. Inhalation will enhance counternutation (extension) and exhalation will enhance nutation (flexion). This would then combine articulatory and muscle energy principles. 29

Lumbar Soft Tissue: Prone Traction Stand at the side of your prone patient.

force (inhibitory pressure) with each hand in opposing directions.

one side of the spinous processes, with similar action and can capitalize on the respiratory cycle to aid this process.

eminence of each hand on the paravertebral muscles lateral to the spinous processes.

32 Lumbar Soft Tissue: Prone Traction Stand at the side of your prone patient. One hand is placed over the sacrum with the fingers directed caudal, the other hand is placed over the lumbosacral junction with fingers directed cephalad Exert a mild anterior force (inhibitory pressure) with each hand in opposing directions. (superior and inferior) This force can be sustained or intermittent to accomplish decompression of LS junction or paraspinal muscle softening You may place the cephalad hand on one side of the spinous processes, with similar action and can capitalize on the respiratory cycle to aid this process. Thoracic (And/or Lumbar) Prone or Lateral Recumbent Pressure Stand at the side of the prone patient On the opposite side of the area to be treated, place the thumb and thenar eminence of each hand on the paravertebral muscles lateral to the spinous processes. Exert an anterolateral pressure on the soft tissues, directed laterally away from the spine, bowstringing the musculature. Maintain the pressure as a sustained inhibitory pressure, or use it in an intermittent fashion to soften hypertonic musculature. Repeat as necessary at various levels. This can also be conducted on the lateral recumbent patient. Modified Lumbar Soft Tissue Lateral Recumbent Video Example: Modified Lumbar Soft Tissue Lateral Recumbent Dr. Kessler

Apply an anterior and lateral force, to stretch the lumbar paravertebral tissues bowstringing the musculature Allow the ASIS to return to the table, while maintaining and gently increasing the

33 Lumbar: Prone Pressure with Counter Leverage Stand at the side of your prone patient. Contact the lumbar paravertebral muscles on the contralateral side of the spine with the heel of your cephalad hand. Contact the ASIS with your caudal hand, inducing a posterior force. Apply an anterior and lateral force, to stretch the lumbar paravertebral tissues bowstringing the musculature Allow the ASIS to return to the table, while maintaining and gently increasing the resistance of your cephalad hand further stretching the paravertebral muscles. Repeat as necessary at additional levels to reduce hypertonic lumbar musculature. ***Viscerosomatic Reflexes*** T1-5 Heart T2-7 Lungs T2-9 Upper GI Tract T2-8 Esophagus T5-9 Stomach and Duodenum T8-L2 Mid and Lower GI Tract T9-11 Small Intestine through ascending colon T8-L2 Transverse colon through rectum T10-L2 Vasomotor to Lower Extremities T10-L2 Genitourinary Tract T10-L1 Kidneys and upper ureter L1-2 Lower ureter T11-L2 Bladder T10-11 Testes/Ovaries T10-L2 Uterus & Cervix T11-L2 Penis/anterior vaginal wall & Clitoris L1-2 Prostate 31

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DIAGNOSIS ANTERIOR PELVIC ROTATION DIAGNOSIS DIAGNOSIS. Direct techniques to treat sacrum and pelvis somatic dysfunction (HVLA, MET)

DIAGNOSIS ANTERIOR PELVIC ROTATION DIAGNOSIS DIAGNOSIS. Direct techniques to treat sacrum and pelvis somatic dysfunction (HVLA, MET) American Academy of Osteopathy Convocation PHYSICIAN STUDENT Thursday, March 18, 2010 Friday, March 19, 2010 2:30 4:00 PM 8:00 9:30 AM 4:30 6:00 PM 10:00 11:30 AM Direct techniques to treat sacrum and