Block 4 OPP Lecture Notes

Physiologic Motion of the Spine

Objectives

- Identify the three principles of physiologic motion of the thoracolumbar spine.- Identify and differentiate the terms neutral, easy normal, physiologic barrier, restrictive

barrier, and anatomic barrier.- Correctly identify osteopathic diagnoses for the thoracolumbar spine when given

appropriate motion and palpatory information.

Anatomy

- A vertebral unit is:- Two vertebrae- The disk- Other connecting elements between them

- Superior facets of articular processes- Cervical

- Coronal plane- Backwards, upwards, medial- BUM

- Thoracic- Coronal plane- Backwards, upwards, lateral- BUL

- Lumbar- Sagittal plane- Backwards, upwards, medial- BUM

Movements of the Spine

- Rotational- Flexion/extension- Rotation- Sidebending (lateral flexion)

- Translational- Anterior/posterior- Lateral- Compression or distraction

- ROM is limited by:- Thickness, elasticity, and compressibility of discs- Shape and orientation of zygapophysial joints- Tension of articular capsules of facet joints- Resistance of back muscles and ligaments

Block 4 OPP Notes! Physiologic Motion of the Spine

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Nomenclature

- Somatic dysfunction is named for the direction of ease of motion- The opposite of the segmentʼs restriction of motion

- Vertebral segmental motion- Refers to the motion of one segment relative to the segment below it- Reference point is the superior, anterior aspect of the vertebral body

- Abbreviations- F - flexion- E - extension- N - neutral- NN - non neutral- S - sidebending- R - rotation- RS - rotation and sidebending to the same side- SR - side bending and rotation to the opposite side

Spinal Motion

- Flexion- Axis - transverse- Plane of motion - sagittal- Spinous process - separation from one below- Transverse process - separation from one below

- Extension- Axis - transverse- Plane of motion - sagittal- Spinous process - approximation with one below- Transverse process - approximation with one below

- Rotation- Axis - vertical- Plane of motion - transverse- Spinous process - posterior on side toward which it rotates

- Posterior right TP = Rr- Transverse process - slight movement toward the side opposite to the rotation

- Sidebending- Axis - anteroposterior- Plane of motion - coronal (frontal)- Spinous process -

- Convex side: separation from one below- Concave side - approximation (side bent toward this)

- Transverse process - not usually examined


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Principles of Physiologic Motion

- Commonly called Fryetteʼs Principles- Generalizations of thoracolumbar movement- Principle I

- When the thoracolumbar spine is in neutral position- Side-bending and rotation occur in opposite directions- Type I somatic dysfunction

- The segments do not return to neutral when the patient does- A neutral SRRL would have restricted right rotation

- Mechanics- No extreme of flexion or extension- Sidebending “X” followed by rotation “Y”- Commonly occur in groups- Commonly cause discomfort but not pain- Usually chronic- Muscles involved are the long restrictors

- Principle II- When the thoracolumbar spine is flexed or extended (non-neutral)- Sidebending and rotation in a single vertebral unit occur in the same direction- Type II somatic dysfunction

- Segment does not return to neutral when the patient does- A non-neutral RRSR would have restricted left rotation

- Mechanics- Extremes of flexion and extension- Rotation “X” followed by sidebending “X”- Typically occurs at one segment- Commonly cause acute pain- Muscles involved are the short restrictors

- Principle III- Initiating motion of a vertebral segment in any plane of motion will modify the

movement of that segment in other planes of motion (generally reducing it).- There is not a corresponding Type III somatic dysfunction.

Spinal Segmental Generalizations

- Thoracic and lumbar spine- Type I mechanics in neutral- Type II mechanics in flexion or extension


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Cervical Spine

- OA- Side bending and rotation to opposite directions- But in all sagittal positions

- AA- Nearly pure rotational mechanics

- C2-7- Named similar to Type II- Rotate and side bend to the SAME SIDE- But in all sagittal positions


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Lower Extremity Muscle Energy

Objectives

- Correctly identify the lower extremity diagnosis and muscle energy techniques for:- Internally externally rotated tibia- Anterior and posterior fibular head- Anterior talus (plantar flexed)- Inverted and everted navicular- Everted cuboid- Hip restrictors

Contraindications

- Fracture- Dislocation- Rheumatologic conditions- Painful tissue damage- Infection of ligamentous, tendon, and muscle tissues or joints- Muscle spasm- Positioning that compromises vasculature- Uncooperative patient or one incapable of cooperation- Evocation of increased neurologic symptoms

Muscle Energy Treatment Steps

- Position the body to treated at the point of initial restriction of motion- Describe to the patient what you want him to do, in what direction, with what intensity

and duration- Direct the patient to contract the appropriate muscle(s)- Apply counterforce equal to and opposite to the patientʼs force- Maintain the force until the contraction is palpated at the appropriate location

(generally, 3-5 seconds)- Tell the patient to stop his contraction, and simultaneously match the patientʼs

decreased force- Allow the patient to relax; sense the tissue relaxation- Take up the slack to the new initial barrier

- This slowly, passively lengthens the muscle- Repeat three to five times, or until the best possible increase in motion is obtained- Retest

Block 4 OPP Notes! Lower Extremity Muscle Energy

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Tibiofemoral Motion

- Knee flexion- Tibia internal rotation- Association with short leg

- Knee extension- Tibia external rotation- Association with long leg

- During extension movement, the larger articular surface of the medial joint surface allows for external rotation of the tibia.

- As the knee returns to flexion this results in internal rotation of the tibia.

Screening for Tibial Dysfunction

- Patient seated at the edge of the table with legs freely suspended.- Close pack the ankle by dorsiflexing the foot to at least 90°. - Passively test internal and external rotation bilaterally (looking for range of motion and

“hard end feel”)

Internally Rotated Tibia

- Patient sits at the tableʼs edge with legs suspended- Physician uses one hand for monitoring and fine tuning at the proximal tibia- Physician uses lower hand at the foot to close pack the ankle with dorsiflexion- Using the lower hand, externally rotate the tibia to the “feather edge” of the restrictive

barrier- Patient is instructed to turn their foot inward (internally rotate) against the physicianʼs

unyielding counterforce for three to five seconds- After the patient relaxes, engage the new barrier by externally rotating the tibia to the

new “feather edge”- Repeat 3-5 times (until restriction releases)


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Externally Rotated Tibia

- Patient sits at the tableʼs edge with legs suspended.- Physician uses one hand for monitoring at the proximal tibia.- Physician uses lower hand at the foot to close pack the ankle with dorsiflexion. - Using the lower hand, internally rotate the tibia to the “feather edge” of the restrictive

barrier. - Patient is instructed to turn their foot outward (externally rotate) against the physicianʼs

unyielding counterforce for three to five seconds. - After the patient relaxes, engage the new barrier by externally rotating the tibia to the

new “feather edge”.- Repeat 3-5 times.

Fibular Motion

- Reciprocal motion:- Anterior glide of fibular head

- Posterior motion of distal fibula- External rotation of tibia/ankle

- Posterior glide of fibular head- Anterior motion of distal fibula- Internal rotation of tibia/ankle

Diagnosis of Fibular Head Dysfunction

- Patient is seated at tableʼs edge with legs freely suspended.- Physician anchors patientʼs lower legs together by placing them between the

physicianʼs lower legs creating a nearly ninety degree angle. - Contact both fibular heads simultaneously by contacting the fibular head with your

thumbs and index fingers.- Test posteromedial glide and anterolateral glide.

Diagnosis of Fibular Head Dysfunction

- Anterior fibular head- Proximal fibular head will NOT glide posteromedially with motion testing- Proximal fibular head WILL glide anterolaterally with motion testing

- Posterior fibular head- Proximal fibular head will NOT glide anterolaterally with motion testing- Proximal fibular head WILL glide posteromedially with motion testing


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Muscle Contraction to Facilitate Correction

- For an anterior fibular somatic dysfunction, dorsiflex the foot to place tension on the plantar flexor muscles.

- Patient contracts these muscles to move the fibular head backwards to treat anterior fibular head somatic dysfunction.

Treatment of Anterior Fibular Head Dysfunction

- Patient sits at the tableʼs edge with legs suspended. - Physician contacts the fibular head and applies a posteromedial force. - The physicianʼs other hand:

- Inverts the foot (to loose pack the fibula)- Externally rotates the tibia- Dorsiflexes the foot to place the plantar flexor muscles on mild tension

- The patient is instructed to evert and plantarflex (push down and out) the foot to use the plantar flexor muscles to move the fibular head posterior.

- Contraction is maintained against the physicians counterforce for 3-5 seconds.- Fine tune to engage the new “feather edge” of the barrier- Repeat 3-5 times (until restriction releases)

Muscle Contraction to Move a Bone

- For a posterior fibular head somatic dysfunction, plantar flex the foot to place tension on the dorsiflexor muscles.

- Patient contracts these muscles to move the fibular head forwards to treat posterior fibular head somatic dysfunction.

Treatment of Posterior Fibular Head Dysfunction

- Patient sits at the tableʼs edge with legs suspended. - Physician contacts the fibular head and applies a anterolateral force. - The physicianʼs other hand:

- Inverts the foot (to loose pack the fibula)- Internally rotates the tibia- Plantar flexes the foot to place the dorsiflexor muscles on mild tension

- The patient is instructed to evert and dorsiflex (turn foot up and out) the foot to use the drsiflexor muscles to move the fibular head anterior.

- Contraction is maintained against the physicians counterforce for 3-5 seconds.- Fine tune to engage the new “feather edge” of the barrier- Repeat 3-5 times (until restriction releases)


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Tibiotalar Joint

- Major motions:- Dorsiflexion (5-40° ROM)- Plantar flexion (10-55° ROM)

- Minor motion:- Posterior glide- Anterior glide

- Studies suggest that people with inflexible ankle joint have a 5X GREATER risk for ankle sprains than those with average flexibility

- 15° for dorsiflexion and 40° for plantar flexion- Recurrent somatic dysfunction in the ankle tends to be associated with plantar

flexion (anterior talus dysfunction)- Ankle sprains are more likely to occur when the tibiotalar joint tends to be

plantar flexed

Diagnosis of Anterior Talus (Plantar Flexed)

- Patient sits with feet suspended off the table.- Physician grasps each foot of the patient with thumbs contacting the anterior aspect of

the talus. - Physician introduces dorsiflexion and posterior glide. - The anterior talus will be apparent with limited dorsiflexion and posterior glide as well

as “hard end feel”.

Treatment of Anterior Talus

- Patient sits on the edge of the table. - Physician places one hand under the plantar surface of the patientʼs foot and the web

of the other hand over the talus. - The foot is dorsiflexed to the barrier. - Patient plantar flexes foot against the physicianʼs unyielding counterforce. - Contraction is maintained for 3-5 seconds followed with a few seconds of relaxation. - Fine tune to reach the new feather edge of the barrier. - Cycle is repeated until adequate release is obtained.


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Cuboid and Navicular Bones

- When the navicular “drops”:- It externally rotates around an AP axis- Inversions: lower portion turns inward

- When the cuboid “drops”:- It internally rotates around an AP axis- Eversion: lower portion turns outward- External rotation = inversion- Internal rotation = eversion

- In an inversion ankle sprain- The cuboid bone commonly “drops”- Goes into internal rotation or eversion

Diagnosis of Inverted or Everted Navicular Bone

- Palpate the patientʼs midline plantar surface of the foot to assess the medial tubercle of the navicular bone for dysfunction.

- Next, one hand stabilizes the talus with the web of the hand and the fingers and thumb curled around this bone.

- The other hand contacts the navicular bone to assess internal and external rotation.

Inverted Navicular Bone (Externally Rotated)

- One hand stabilizes the talus with the web of the hand and the fingers and thumb curled around the talus.

- The other hand contacts the navicular bone. - Physician everts (internally rotates) the navicular bone to the barrier. - Patient uses muscle effort to invert the foot against physicianʼs unyielding

counterforce.

Everted Navicular Bone (Internally Rotated)

- One hand stabilizes the talus with the web of the hand and the fingers and thumb curled around the talus.

- The other hand contacts the navicular bone. - Physician inverts (externally rotates) the navicular bone to the barrier. - Patient uses muscle effort to evert the foot against physicianʼs unyielding

counterforce.


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Diagnosis of Everted Cuboid (Internally Rotated)

- Physician assesses the medial plantar aspect of the cuboid bone assessing for dysfunction.

- The medial aspect of the cuboid will be found to be “dropped” and resist external rotation movement.

Treatment of Everted Cuboid (Internally Rotated)

- Physician stabilizes the calcaneus maintain the foot in 90° of flexion. - Physicianʼs other hand makes contact with the lateral foot with the middle and ring

fingers overlying the plantar aspect of the cuboid while the heel of the hand contacts the dorsal surface of the 4th and 5th metatarsal bones.

- The feather edge of the barrier is engaged by placing a cephalad force through the plantar contact and a caudad force through the base of the thumb.

- Patient then dorsiflexes the foot against the physicianʼs unyielding counterforce. - Contraction is maintained for 3-5 seconds followed with a few seconds of relaxation. - Physician fine tunes to engage the feather edge of the new barrier. - Contraction cycle is repeated 3-5 times until adequate release is obtained.

Abductor Restriction

- Physician ABducts the leg to the barrier. - Physician provides counterforce and supports the patientʼs knee. - Physician uses caudad hand for fine tuning. - Physician uses cephalad hand to stabilize the pelvis. - Patient makes their muscle effort by bringing the involved extremity back to midline (for

3-5 seconds).- After the patient relaxes for several seconds,

- Physician repositions to the new feather barrier. - Cycle is repeated 3-5 times until restriction is resolved.

Adductor Restriction

- Physician ADducts the leg to the barrier. - The patient is asked to move their leg outward (abduct) against the physicianʼs

counterforce for 3-5 seconds. - The patient then relaxes for several seconds. - Physician fine tunes. - Cycle is repeated 3-5 times.


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Treatment of Quadricep Restriction

- Physician flexes the lower leg to the barrier. - Patientʼs lower leg is placed against the physicianʼs chest/shoulder to provide

counterforce. - Patient is asked to straighten their leg for 3-5 seconds. - Patient relaxes. - Physician repositions to the new barrier. - Cycle is repeated 3-5 times.

Treatment of Hamstring Restriction

- Patient is supine on the table. - Physician is on the same side of the table as the involved extremity. - Physician places patientʼs Achilles tendon on the physicianʼs shoulder. - Physicianʼs hands are placed just proximal to the patientʼs knee. - Patient is asked to simultaneously bring their heel into your shoulder and bringing their

knee towardʼs their own head. - Effort is for 3-5 seconds. - Patient relaxes. - Physician repositions to the new barrier. - Cycle is repeated 3-5 times until an effective release is achieved.

Treatment of External Rotation Restriction

- Patientʼs involved extremity is taken to the barrier. - Physician assures patientʼs knee is at 90°. - Physicianʼs hand is at the lateral malleolus to provide a point of resistance. - Patient is asked to push their ankle into the physicianʼs hand for 3-5 seconds. - Patient relaxes. - Physician externally rotates the patientʼs extremity to the new edge of the restrictive

barrier. - Cycle is repeated 3-5 times. - Rescreen!

Diagnosis of Internal Rotation Restriction

- Patientʼs internal rotation of the thigh is restricted by tight external rotators. - Both legs can be tested and compared at the same time with the patient in the prone

position.


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Treatment of Internal Rotation Restriction

- Physicianʼs hand is placed against the medial malleolus of the involved extremity. - Physician internally rotates the extremity to the edge of the barrier. - Patient is asked to bring their ankle into the physicianʼs hand for 3-5 seconds. - Physician repositions to the edge of the new restrictive barrier. - Cycle is repeated 3-5 times until an effective release occurs.


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Lumbar Somatic Dysfunction: Diagnosis and Muscle Energy

Objectives:

- Identify and discriminate the diagnostic sequence and criteria for lumbar somatic dysfunction.

Type I Somatic Dysfunction

- In neutral- Usually a group of vertebrae- Side-bending and rotation are in opposite directions- Exists because the segments do not return to neutral when the patient does- Position of initial injury:

- Patient in neutral was side-bend toward one direction while rotating in the other- Also commonly occurs as a compensatory pattern

Type II Somatic Dysfunction

- Non-neutral mechanics- In flexion or extension- Usually a single vertebra- Side-bending and rotation are in the same direction- Exists because the segment does not return to neutral when the patient does- Position of initial injury:

- Patient was flexed or extended, with side-bending and rotation to one side

Principle III

- Initiating motion of a vertebral segment in any plane of motion will modify the movement of that segment in other planes of motion (generally reducing it).

- There is not a corresponding Type III somatic dysfunction

Block 4 OPP Notes! Lumbar Somatic Dysfunction: Dx and ME

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Sequence of Lumbar Examination for Somatic Dysfunction

- Initial postural screening, scoliosis screen, and neurologic exam. - Regional exam

- Visual inspection- AROM/PROM (F,E,S,R)- TART

- Segmental exam- TART to identify segmental dysfunction- Segmental PROM in neutral to identify segment- Segmental PROM in flexion and extension to determine diagnosis

Diagnosing Segmental Dysfunction

- Palpate the region to find significant posterior transverse processes. - You will find other TART criteria there if the asymmetry indicates somatic

dysfunction. - When you locate one, use segmental PROM in neutral to identify the rotation

component. - Flex the patient to/through the segment (but not through the one inferior) to see if the

asymmetry improves greatly, or disappears.- If it does, it is a flexion somatic dysfunction. - FRXSX

- Extend the patient to/through the segment (but not through the one inferior) to see if the asymmetry improves greatly, or disappears.

- If it does, it is an extension somatic dysfunction. - ERXSX

- If the transverse process does not essentially blend in while the patient is in either flexion or extension, it is a neutral somatic dysfunction.

- NSXRY- Technique:

- Compress both thumbs firmly toward the transverse processes. - Then, sequentially push each one anteriorly. - The one that resists anterior motion is the posteriorly-rotated transverse

process. - This identifies the rotational component. - Retest in flexion and extension. - You can side-bend by translation to determine the side-bending component.

- You may also deduce it by applying these two principles:- If the dysfunction disappears in F or E, it is Type II- If the dysfunction is most noticeable in neutral it is Type I


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Common Errors in Muscle Energy

- Wrong diagnosis- Initial position for treatment is not localized- Not monitoring motion at the involved joint- Too forceful a muscle contraction by the patient- Too short a duration of muscle contraction by the patient- Not allowing the patient to totally relax before repositioning to new restrictive barrier

(forcing the new motion barrier).- Forgetting to retest (the 11th commandment)

Treatment

- When you find the diagnosis, reverse the position to treat the patient.

Example - Lumbar Type II Flexion Dysfunction, Seated Treatment

- L4 FRLSL- Stand or sit behind the patient- With one hand, monitor the interspinous region between L4 and L5, and the transverse

processes of L4. - Bring the patientʼs upper trunk into:

- Extension- Right side bending- Right rotation- Induce these motions down through the L4 segment, but not through L5- To achieve the extension easily, ask the patient to “move your stomach toward

your left thigh.”- Ask the patient to sidebend and rotate to the left, while bending slightly forward,

against your counterforce for 3-5 seconds. - Tell the patient to “Stop… relax.”- When the patient relaxes, take up the slack to engage the next right sidebending, right

rotation, and extension restrictive barriers. - Repeat this cycle 2-4 times or until motion is adequately improved. - Retest.


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Example - Lumbar Type II Extension Dysfunction, Seated Treatment

- L4 ERRSR- Stand behind or sit to the side of the patient, on the side of the rotation. - Ask the patient to place his right hand on his left shoulder. - Place your arm under the patientʼs right axilla and over the patientʼs left shoulder with

your hand over his to control the shoulder. - Monitor the interspinous region between L4 and L5 and the transverse processes of

L4 with your other hand. - Bring the patientʼs upper trunk into flexion, left sidebending, and left rotation through

the L4 segment. - Ask the patient to attempt to rotate and sidebend to the right while slightly leaning

backward, against your counterforce for 3-5 seconds. - Tell the patient to “Stop… relax.”- When the patient relaxes, take up the slack to engage the next left sidebending, left

rotation, and flexion restrictive barriers. - Repeat this cycle 2-4 times or until there is adequate motion improvement. - Retest.

Example - Lumbar Type I, Seated Treatment

- L2-4 NSLRR- Stand on the side opposite to the rotation dysfunction. - Have the patient place his left hand over the right shoulder. - Put your left arm under the patientʼs left arm, with your hand over the patientʼs hand on

his shoulder. - Place your right thumb at the apex of the convexity (L3 in this case). Alternatively, you

can use a tripod hold on the spinous process and transverse processes with two fingers and a thumb to monitor the apex segment.

- Maintain the spine in neutral.- Sidebend the trunk to the right and rotate the upper trunk to the left until you fel the

motion reach L3 (the apex segment).- Have the patient attempt to sidebend to the left and rotate to the right against your

counterforce for 3-5 seconds. - Tell the patient to “Stop… relax.”- When the patient relaxes, take up the slack to engage the next right sidebending and

left rotation restrictive barriers. - Repeat this cycle 2-4 times or until there is adequate improvement in motion. Retest.


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Lower Somatic Dysfunction: Diagnosis and Muscle Energy 2

Objectives

- Identify and discriminate the following:- Diagnostic sequence and criteria- Nomenclature- Given appropriate information, name the diagnosis and the related diagnostic

principle or type of dysfunction

Lumbar Type 2 Dysfunction

- Example - L3 ESRRR- Have the patient lie in the lateral recumbent position with the posterior transverse

process up. - Flex the hips until you feel motion at the dysfunctional joint (isolating forces to the

dysfunctional joint from below). - If the patient has an extension diagnosis, induce slight flexion to the dysfunctional

vertebra by pulling the shoulders forward. - If the patient has a flexion diagnosis, induce slight extension to the dysfunctional

vertebra (by pushing the knees posterior until you feel the lumbar spine extend to the segment).

- Have the patient rotate the shoulder forward slightly until you palpate that the rotational barrier is engaged at the dysfunctional segment.

- Have the patient reach for the floor with the hand on the side of the dysfunctional segment (this helps pull the vertebra toward neutral rotation). You should be able to feel motion at your hand at the segment.

- Repeat this two times.- Gently lower the patientʼs ankles toward the floor until you feel sidebending at the

restricted segment.- Have the patient push the feet directly toward the ceiling as you resist 3-5 seconds,

then stop and relax. You should feel the muscles activate at your monitoring hand.- Adjust to the new barrier and repeat 2 – 4 times.- Retest.- Muscle energy types: the upper body is used to pull the vertebra back into place; the

lower body is used with post-isometric stretch.

Block 4 OPP Notes! Lumbar Somatic Dysfunction: Dx and ME 2

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Lateral Recumbent FRS

- Example: L5 FRRSR- Patient is lateral recumbent with the posterior transverse process down.- Palpate the interspinous space between L5 and S1 with the cephalad hand.- Flex and extend the hips to localize at L5/S1.- Flex the upper leg slightly farther so that it is gently dropped off the side of the table.- Rotate the pelvis slightly anteriorly until you feel slight resistance at L5/S1. (Pelvis is

being rotated right, leaving L5 rotated left.)- Change hands so that the caudad hand is now palpating, while the cephalad hand

rotates the spine posterior from the shoulder down until resistance reaches L5. (L5 is being rotated left and slightly extended.)

- Ask the patient to pull the posterior shoulder forward while you resist. Make sure you feel the effort reach your palpating hand.

- Tell the patient to stop. After the patient relaxes, carry the shoulder posteriorly until the new restrictive barrier is felt. (X3)

- Ask the patient to gently pull the hip backward against your resistance.- Tell the patient to stop. After the patient relaxes, gently carry the hip forward to the

new restrictive barrier. (X3)- Return to neutral and retest.- This technique relies on treatment of the rotational and flexion components.

Lateral Recumbent ERS

- Example: L3 ERLSL- Patient in lateral recumbent position, posterior transverse process up.- Isolate forces from below (flexing the hips) and above (using the trunk to rotate the

segment toward the table) to the restricted segment.- Have the patient reach for the floor while breathing in (breathing in decreases lumbar

extension) for 3-5 seconds, then stop and relax. (X3)- Lower the legs toward the floor until you palpate initial resistance at the dysfunctional

segment.- Have the patient raise the legs toward the ceiling as you resist, then stop and relax.- Readjust to the new restrictive barrier.- Repeat 3-5 times.- Retest.- This technique addresses rotation by pulling the vertebra back into place, sidebending

by post-isometric relaxation and stretch, and extension through respiratory cooperation.


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Lumbar Type I Treatment Positioning and Rotation

- Example: L2-4 NSRRL- Position the patient.- Have the patient lie on the side of the posterior transverse processes, with the spine in

neutral position.- Palpate the apex segment in the group curve with one hand.- Flex the thighs until you feel motion at that segment. - Rotate the shoulder posteriorly until you feel the rotation at the apex segment.- Step 1

- Have the patient push the shoulder forward against counterforce by your hand or forearm for 3-5 seconds. You should feel the muscles activate at your monitoring hand.

- Tell the patient to “Stop, relax.” - When the patient relaxes, take up the slack by rotating the shoulder until the

next restrictive rotational barrier is engaged.- Repeat this cycle 2 times.- The rotational component is addressed with the multifidus and rotatores.

- Step 2- Lower the patientʼs feet until you have localized sidebending to the apex

segment.- Have the patient push the feet toward the ceiling for 3-5 seconds against your

equal counterforce. Make sure that the patientʼs muscle effort is sufficient so that you can feel the muscles engage at your monitoring hand.

- Tell the patient to “Stop, relax.” - When the patient relaxes, take up the slack until the next restrictive sidebending

barrier is engaged.- Repeat this cycle 2-4 times or until there is adequate improvement in motion.- Retest. - Sidebending is addressed with the quadratus lumborum.

- Address the rotation from the shoulder down to the segment.- Address the sidebending from the legs up to the segment.


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Pelvic (Iliosacral) Diagnosis

Objectives

- On an exam the student will discriminate:- Iliosacral structure and function- Motions- Somatic dysfunction- Indiations- Contraindications- Muscle energy techniques for the following:

- Superior innominate shear- Inferior innominate shear- Superior pubic shear- Inferior pubic shear- Pubic compression- Anterior innominate rotation- Posterior innominate rotation- Outflare innominate- Inflare innominate

Movement of Innominates

- Physiologic- The muscles, connective tissue, and joints remain in positions that are normally

a part of physiologic motion but are dysfunctional when the body should have returned to a neutral position but did not do so.

- Rotation- Anterior or Posterior

- Flare- Inflare or Outflare

- Non Physiologic- Generally induced by trauma. It is evidenced by the joint, muscle, and

connective tissue elements being in positions and/or relationships that are not part of the physiologic range of motion and do not involve the physiologic axes of motion.

- Innominate Shear- Inferior/superior

- Pubic Shear- Inferior/superior

Block 4 OPP Notes! Pelvic (Iliosacral) Diagnosis

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Rotation of the Innominates

- Innominates rotate around the inferior transverse axis of the sacrum. - Located at inferior part of sacroiliac joint. - S: pubic symphysis- H: acetabulum- X: inferior transverse axis


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Steps to Diagnose Iliosacral (IS) Dysfunction

- Screening:- Standing flexion test

- If screening test is positive, then determine the following to make a specific diagnosis:- ASIS level- Distance from umbilicus to ASIS- Pubic rami level- Supine leg lengths- PSIS level- Prone leg lengths

Standing Flexion Test

- A screening test that determines the side of iliosacral somatic dysfunction (IS) (motion of ilium on the sacrum).

- Identifies the side of dysfunction- Have the patient stand with feet shoulder with apart, back to doctor- Locate the PSISs- The physicianʼs thumbs are placed on the inferior slope of the patientʼs PSISs with the

fingers resting on the superolateral surface of the iliac crests. - The physician maintains a firm pressure on the PSISs to ride with the bony landmarks,

not shift due to skin or fascial drag.- The patient is instructed to actively bend forward at the waist and slowly try to touch

her toes. - Allow pelvis to come back towards you so that the patient does not fall forward

- The physician keeps their eyes level with the PSISs. He will have to rise as the patient bends forward.

- Observe the movement under thumbs- The test is positive when asymmetry of the thumbs occurs. - The side of a positive test is the one where the thumb on the PSIS moves the most

cephalad (the furthest) at the end range of motion the test. - False-positive test

- A false-positive test can be created by a:- Leg-length discrepancy > ½ inch- Contralateral tight hamstring- Contralateral tight iliopsoas muscle- A unilateral sacral dysfunction

- If this test is negative, the presence of an iliosacral (IS) dysfunction is highly unlikely. - The side of a positive test is the one where the thumb on the PSIS moves the most

cephalad (the farthest) at the end range of motion the test.


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“Reseat” the Pelvis - Supine

- Patient bends knees- Asks the patient to lift hips up off table- Patient is then asked to return hips to table and straighten legs

- Passively or Actively- Alternate: This can also be done passively by the physician picking up the pelvis and

placing it down. (Method of choice in patients with knee dysfunction or pain)

ASIS Level

- Put thumbs horizontally under the ASISs- Are they level? - Or is the side of the positive standing flexion test inferior or superior relative to

the other side?

Innominate Inflare/Outflare

- Visualize a line from each ASIS to umbilicus- Is the side with the positive standing flexion test relatively farther (outflare) or

closer (inflare) to umbilicus?

Pubic Rami Levels

- Place your fingers on the superior aspect of the pubic rami- Is the positive standing flexion side inferior or superior relative to the other side?

Leg Length Supine

- Place thumbs on the inferior aspect of the medial malleoli- Compare leg lengths bilateral by comparing thumb positions without putting traction on

either side

“Reseat” The Pelvis - Prone

- Doctor bends patientʼs knees, then returns legs to table- Alternative: Doctor can lift patientʼs hips, center them over table- This must be done PASSIVELY and slowly and carefully


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Leg Lengths Prone

- Have thumbs on the inferior aspect of the medial malleoli- Compare position bilaterally

PSIS

- Place thumbs horizontally on the inferior aspect the PSISs- Are they level? - If not, is the positive standing flexion side inferior or superior relative to the

other side?

Possible Diagnosis: Iliosacral (IS)

- Somatic dysfunctions using the previous physical findings:- Superior Innominate Shear- Inferior Innominate Shear- Superior Pubic Shear- Inferior Pubic Shear- Pubic Compression- Anterior Innominate Rotation- Posterior Innominate Rotation- Outflare Innominate- Inflare Innominate

Iliosacral Somatic Dysfunction - Innominate Shears

- Superior shear (up slip) right- Positive right standing flexion test- Superior right ASIS- Superior right PSIS

- Superior shear (up slip) left- Positive left standing flexion test- Superior left ASIS- Superior left PSIS

- Inferior shear (down slip) right- Positive right standing flexion test- Inferior right ASIS- Inferior right PSIS

- Inferior shear (down slip) left- Positive left standing flexion test- Inferior left ASIS- Inferior left PSIS


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Iliosacral Somatic Dysfunction - Pubic Rami Shears

- Superior right- Positive right standing flexion test- Superior right pubic tubercle- Tense, tender right inguinal ligament

- Superior left- Positive left standing flexion test- Superior left pubic tubercle- Tense, tender left inguinal ligament

- Inferior right- Positive right standing flexion test- Inferior right pubic tubercle- Tense, tender right inguinal ligament

- Inferior left- Positive left standing flexion test- Inferior left pubic tubercle- Tense, tender left inguinal ligament

Iliosacral Somatic Dysfunction - Pubic Rami Compression

- Pubic compression- Standing flexion test +/-- ASIS equal- PSIS equal- Bilaterally tender pubic rami- Tender pubic symphysis


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Iliosacral Somatic Dysfunction - Innominate Rotations

- anterior rotation right- Positive right standing flexion test- Inferior right ASIS- Superior right PSIS

- Anterior rotation left- Positive left standing flexion test- Inferior left ASIS- Superior left PSIS

- Posterior rotation right- Positive right standing flexion test- Superior right ASIS- Inferior right PSIS

- Posterior rotation left- Positive left standing flexion test- Superior left ASIS- Inferior left PSIS

Iliosacral Somatic Dysfunction - Innominate Flares

- Outflare right- Positive right standing flexion test- Lateral right ASIS- Medial right PSIS

- Outflare left- Positive left standing flexion test- Lateral left ASIS- Medial left PSIS

- Inflare right- Positive right standing flexion test- Medial right ASIS- Lateral right PSIS

- Inflare left- Positive left standing flexion test- Medial left ASIS- Lateral left PSIS


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Indications for IS Muscle Energy

- Common patient complaints that require evaluation of the sacrum and pelvis include, but are not limited to:

- PAIN- abdominal pain, pelvic pain, dysmenorrhea (painful menstrual period), lower

back pain, lower extremity neuralgia- SOMETHING IS NOT WORKING CORRECTLY

- pregnancy, post delivery, urinary tract complaints, prostatitis, incontinence, lower gastrointestinal issues, irritable bowel syndrome, constipation, decreased range of motion of the lower extremities, balance problems.

Contraindications

- Fracture of lumbar, pelvis or sacrum- Dislocation- Rheumatologic conditions which cause instability- Painful tissue damage including tears, hematoma- Infection of ligamentous, tendon, and muscle tissues or joints

- Acute abdomen (where surgical treatment is necessary)- Centrally mediated muscle spasm- Positioning that compromises vasculature- Uncooperative patient or one incapable of cooperation- Evocation of increased neurologic symptoms

- Patient cannot tolerate positioning

HIPSLIT

- Treatment sequence for the pelvis- Hip long restrictors- Innominate shears (up-slip or down-slip)- Pubic dysfunctions- Lumbars (non-compensated L5)- Sacroiliac dysfunctions- Innominate rotations and flares- Thoracic dysfunctions


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Lumbar HVLA

Objectives

- Indications and contraindications for performing HVLA- Diagnosis of lumbar segments using the HVLA model- Steps in treating Type 1 and Type 2 lumbar somatic dysfunctions with HVLA

Indications

- Articular somatic dysfunction of the lumbar spine- Specific Joint Mobilization

- To free motion in somatic dysfunction- To improve biomechanical function- To reduce pain- To reduce somatovisceral reflex

- Exercise caution in cases of acute sprain/strain- May need to hold off on using HVLA until inflammation resolves or while waiting for

imaging studies

Contraindications

- Anatomic/pathologic changes such as:- Fracture- Traumatic contracture- Advanced degenerative joint disease- Ankylosis- Severe osteoporosis- Herniated lumbar disc- Vertebral infection- Metastatic disease (especially breast, kidney, lung, thyroid, and prostate

cancers)- Patient refusal

Block 4 OPP Notes! Lumbar HVLA

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Principles

- These techniques can also be done with many patients on T10-12- Initial practice is easier if you start learning with someone approximately your own

size; over time, you learn to adapt for larger and smaller people.- “The pop is not the criterion…” (A. T. Still) Retest, to be sure the articulation had the

desired effect.- Not all HVLA setups reverse all planes of the diagnosis. Sometimes, they are set up

to achieve leverage at a specific level through primarily one mechanism (sidebending or rotation), with the rest of the setup being concerned with locking out inappropriate motion above or below the joint being addressed.

Keys to Success

- Accurate diagnosis- Visual Inspection

- Anterior, lateral, posterior, including spinal curves- Skin Inspection

- General motion testing- AROM, PROM- Scoliosis Screening

- Palpatory assessment (TTA, asymmetry)- Passive segmental motion testing (seated or prone)

- Neutral- Flexion- Extension

- Doing all 3 techniques:- The patient is lateral recumbent, with the posterior transverse process(es)

down.- Stand in front of the lumbar spine- Keep the patientʼs shoulder and hip perpendicular to the table.- Localize to the segment(s) to be treated by flexing the hips until motion reaches

the appropriate level- Then pull the arm closest to the table to induce rotation to the segment(s) from

above.


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Basic Flow

- Transverse process(es) down.- Induce extension if needed.- Localize to the dysfunction from below.- Stabilize the legs and pelvis.- Induce flexion if needed.Pull the lower arm toward you to rotate the torso down

through the dysfunctional segment(s).- Introduce appropriate sidebending:

- Type I: Pull the arm caudad.- Type II: Pull the arm cephalad.

- Place forearms and be sure again that your monitoring hand is in position.- Roll the body as a unit toward you, and take out the slack.- Perform the thrust.- Retest (even if you heard an audible articulation).

Basic Position

- The patient is left lateral recumbent (posterior transverse process down on the table)- You stand in front of the patient at the level of the lumbar spine

The Importance of the Monitoring Hand

- So much depends on localizing your forces to the joint space below the dysfunctional vertebra.

- If your induced motion is not palpable at the monitoring hand, youʼre probably going to be treating somewhere other than the level you want to be treating.

Placement and Localization

- Have the patient lie on the side of the posterior transverse process(es). Shoulders and hips are perpendicular to the table.

- Monitor the dysfunctional segment with one hand. Use your thigh and a hand under the ankles to flex the spine until you feel motion at the dysfunctional joint.

Type II Flexion Somatic Dysfunction: Introduce Extension

- If you are treating a flexion somatic dysfunction, push the knees backward until you induce slight extension at the joint space below the dysfunctional segment.


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Stabilize the Pelvis and Legs

- Have the patient straighten the lower leg. - Tuck the upper legʼs foot into the lower legʼs popliteal fossa.

Type II Extension Somatic Dysfunction: Introduce Flexion

- If you are treating an extension somatic dysfunction, pull the shoulders forward to introduce flexion to the segment.

Rotate the Dysfunctional Vertebra

- Have the patient grasp your elbow, and use his arm to rotate the torso down through the dysfunctional vertebra.

Type II Somatic Dysfunction: Introduce Sidebending

- For a type II somatic dysfunction, pull the arm cephalad to induce sidebending opposite to the dysfunction.

Type I (Neutral) Somatic Dysfunction: introduce Sidebending

- For a neutral (type I) somatic dysfunction, pull the arm caudad in order to induce the appropriate sidebending.

Stabilize the Torso

- Have the patient clasp his wrist to help stabilize the torso.

Forearm Placement

- Place your cephalad forearm against the patientʼs axilla/shoulder.- Place your caudad forearm between the iliac crest and greater trochanter.- Place your hands so they can monitor the dysfunctional segment(s) and joint space.


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The HVLA Thrust

- Ask the patient to inhale/exhale.- Take out any remaining slack in the tissues as the patient exhales.- Apply the high velocity, low amplitude thrust.

Direction of Thrust

- Flexion and extension- Apply the thrust through the forearm on the pelvis with a mild body drop

downward rotating the pelvis anteriorly and cephalad- Direct thrust toward the patientʼs head to encourage side bending

- Neutral- Apply the thrust through your forearm on the pelvis - with a mild body drop downward- rotating the pelvis anteriorly and caudad- Direct thrust so that your arms are separating, increasing the sidebending

toward the table

Thrust for Flexion Dysfunction

- Example: L3 FRLSL- Apply the thrust through the forearm on the pelvis with a mild body drop downward

rotating the pelvis anteriorly and cephalad- Direct thrust toward the patientʼs head to encourage side bending

Thrust for Extension Dysfunction

- Example: L3 ERLSL- Apply the thrust through the forearm on the pelvis with a mild body drop downward

rotating the pelvis anteriorly and cephalad- Direct thrust toward the patientʼs head to encourage sidebending in that direction


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Pelvic (Iliosacral) Diagnosis and ME Techniques

Objectives

- Discriminate iliosacral structure and function, motions, somatic dysfunction, indications, contraindications, and muscle energy techniques for the following:

- Superior Innominate Shear- Inferior Innominate Shear- Superior Pubic Shear- Inferior Pubic Shear- Pubic Compression- Anterior Innominate Rotation- Posterior Innominate Rotation- Outflare Innominate- Inflare Innominate

Steps to Diagnose Ileosacral (IS) Dysfunction

- Screening:- Standing Flexion Test

- If screening test is positive, then determine the following to make a specific diagnosis

- Supine Reseat the Pelvis- ASIS Level- Distance from Umbilicus to ASIS- Pubic rami Level- Supine Leg Lengths

- Prone Reseat the Pelvis- PSIS Level- Prone Leg Lengths

Block 4 OPP Notes! Pelvic (Iliosacral) Diagnosis and ME Techniques

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Standing Flexion Test

- A screening test that determines the side of iliosacral somatic dysfunction (IS) (motion of ilium on the sacrum)

- IDENTIFIES the SIDE of DYSFUNCTION- Have the patient stand with feet shoulder with apart, back to doctor- Locate the PSISs- The physicianʼs thumbs are placed on the inferior slope of the patientʼs PSISs with

the fingers resting on the superolateral surface of the iliac crests. - The physician maintains a firm pressure on the PSISs to ride with the bony landmarks,

not shift due to skin or fascial drag.- The patient is instructed to actively bend forward at the waist and slowly try to touch

her toes. - (Allow pelvis to come back towards you so that the patient does not fall forward)

- The physician keeps their eyes level with the PSISs. He will have to rise as the patient bends forward.

- Observe the movement under thumbs- The test is positive when asymmetry of the thumbs occurs. - The side of a positive test is the one where the thumb on the PSIS moves the most

cephalad (the furthest) at the end range of motion the test- False-positive test

- A false-positive test can be created by a:- leg-length discrepancy >½ inch- contralateral tight hamstring- contralateral tight iliopsoas muscle- a unilateral sacral dysfunction.

- If this test is negative, the presence of an iliosacral (IS) dysfunction is highly unlikely- The side of a positive test is the one where the thumb on the PSIS moves the most

cephalad (the farthest) at the end range of motion the test

“Reseat” the Pelvis - Supine

- Patient bends knees- Asks the patient to lift hips up off table- Patient is then asked to return hips to table and straighten legs- Passively or Actively- Alternate: This can also be done passively by the physician picking up the pelvis and

placing it down. (Method of choice in patients with knee dysfunction or pain)


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ASIS Level

- Put thumbs horizontally under the ASISs- Are they level?- Or is the side of the positive standing flexion test inferior or superior relative to

the other side?

Innominate Inflare/Outflare

- Visualize a line from ASIS to umbilicus- Is the side with the positive standing flexion test relatively father (outflare) or

closer (inflare) to umbilicus?

Pubic Rami Levels

- Place your fingers on the superior aspect of the pubic rami- Is the positive standing flexion side inferior or superior relative to the other side?

Supine Leg Length

- Place thumbs on the inferior aspect of the medial malleoli.- Compare leg lengths bilateral by comparing thumb positions without putting traction on

either side.

“Reseat” the Pelvis - Prone

- Doctor bends patientʼs knees, then returns legs to table- Alternative: Doctor can lift patientʼs hips, center them over table- This must be done PASSIVELY and slowly and carefully

Prone Leg Lengths

- Have thumbs on the inferior aspect of the medial malleoli. - Compare position bilaterally.


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PSIS

- Place thumbs horizontally on the inferior aspect the PSISs- Are they level?- If not, is the positive standing flexion side inferior or superior relative to the

other side?

Three Possible Iliosacral (IS) Diagnoses

- Innominate diagnosis- Shears

- Superior innominate shear- Inferior innominate shear

- Rotations- Anterior innominate rotation- Posterior innominate rotation

- Pubic rami diagnosis- Shears

- Superior pubic shear- Inferior pubic shear

- Pubic symphysis compression- Flare diagnosis

- Outflare innominate- Inflare innominate

Indications

- Common patient complaints that require evaluation of the sacrum and pelvis include, but are not limited to:

- PAIN- abdominal pain, pelvic pain, dysmenorrhea (painful menstrual period),

lower back pain, lower extremity neuralgia- SOMETHING IS NOT WORKING CORRECTLY

- pregnancy, post delivery, urinary tract complaints, prostatitis, incontinence, lower gastrointestinal issues, irritable bowel syndrome, constipation, decreased range of motion of the lower extremities, balance problems, “hitch in the get along”.


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Contraindications

- Fracture of lumbar, pelvis or sacrum- Dislocation- Rheumatologic conditions which cause instability- Painful tissue damage including tears, hematoma- Infection of ligamentous, tendon, and muscle tissues or joints

- Acute abdomen (where surgical treatment is necessary)- Centrally mediated muscle spasm- Positioning that compromises vasculature- Uncooperative patient or one incapable of cooperation- Increased neurologic symptoms- Patient cannot tolerate positioning

HIPSLIT - Treatment Sequence for the Pelvis

- Hip long restrictors- Innominate shears- Pubic dysfunctions- Lumbars (non-compensated L5)- Sacroiliac dysfunctions- Innominate rotations and flares- Thoracic dysfunctions

- Bold highlights are diagnosed and treated with iliosacral (IS) dysfunction

Superior Innominate Shear

- Type of ME: Respiratory Cooperation- Patient is supine with the feet off the end of the table.- Physician places their thigh up to the contralateral foot (non-dysfunctional side)

to stabilize the pelvis and then holds the patientʼs leg (dysfunctional side) just above the ankle.

- The leg is abducted to about 10-15° to loose-pack the sacral iliac joint (SIJ).- The hip is then internally rotated to close-pack the hip joint.- The physician pulls on the leg while the patient performs a series of three to

five inhalation and exhalation efforts, taking up slack between efforts.- During the last exhalation effort the patient is asked to cough while

simultaneously the leg is pulled in a caudal direction.- Retest


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Alternative Superior Innominate Shear

- Type of ME: Post Isometric Relaxation and Respiratory effort- Patient is supine with the feet off the end of the table.- Physician places their thigh up to the contralateral foot (non-dysfunctional side)

to stabilize the pelvis and then holds the patientʼs leg (dysfunctional side) just above the ankle.

- The leg is abducted to about 10-15° to loose-pack the sacral iliac joint (SIJ).- The hip is then internally rotated to close-pack the hip joint.- The physician pulls on the leg while the patient inhales and pulls hip

cephalad 3-5 seconds, 3-5 times.- During exhalation the leg is pulled caudally to take up the slack. Resist the next

inhalation and muscle effort.- Continue to desired effect- Retest

Inferior Innominate Shear

- Type of ME: Post Isometric Relaxation and Respiratory Cooperation- Patient is prone with the physician standing on the same side as the

dysfunction.- The patientʼs foot is held by the physicianʼs hand, the patientʼs knee is flexed

while the other hand is placed on the patientʼs ipsilateral ishial tuberosity.- The leg is abducted to about 10-15° to loose-pack the SIJ.- A cephalad force is placed on the ipsilateral ishial tuberosity while the patient

performs a series of deep inhalation and exhalation efforts.- Additionally, the patient attempts to straighten the ipsilateral arm (that is

holding on the table leg) which results in a caudal force through the trunk.- Retest

Superior Pubic Shear

- Type of ME: Joint mobilization using muscle force- Patient is supine with the physician standing on the side of the dysfunction.- The pelvis is shifted to the edge of the table being sure to maintain stability.- Physicianʼs legs can be utilized to hold the freely hanging leg.- Physician places one hand on the opposite innominate to stabilize the pelvis

while placing the other hand over the distal femur on the dysfunctional side.- Mild hip extension stretch to the barrier is applied.- The patient performs hip flexion muscle effort for three to five seconds. Three- The physician takes-up the “slack” and repeats this process until proper release

is obtained.- Retest


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Inferior Pubic Shear

- Type of ME: Post Isometric Relaxation- Patient is supine with the physician standing on the same side of the

dysfunction.- The patient has the dysfunctional hip and knee flexed while the physician

slightly internally rotates the hip rolling the pelvis to the opposite side.- Physician places the middle and ring fingers around the PSIS (if possible) and

the heel of the hand to the ishial tuberosity.- The pelvis is placed back on the table and a superior and medial force is

applied against the ishial tuberosity.- Physician resists three to five efforts of three to five second muscle effort for the

patient to straighten the leg in a caudal direction.- The physician takes-up the “slack” and repeats this process until proper release

is obtained.- Retest

Pubic Symphysis Reset ME Technique

- Type of ME: Joint mobilization using muscle force- DX: Superior OR Inferior Pubic Shear, OR Pubic Compression- Step A.

- Patient is supine with the hips and knees flexed and feet flat on the table and together.

- Physician stands at the side of the table holding the patientʼs knees together.- Physician resists the patientʼs attempt to abduct both knees for a three to five

second, 3-5 times.- Step B.

- Physician now places the forearm between the patientʼs knees.- The patient adducts against the physicianʼs counterforce three to five times

for up to three to five seconds until release is felt at the pubic symphysis.- Retest


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Anterior Innominate Rotation

- Type of ME: Post Isometric Relaxation- Patient may complain of ipsilateral hamstring tightness and spasm and sciatica.- Patient is supine with the physician standing on the same side of the dysfunction with

the hip and knee flexed.- Physician places the heel of the hand on the ishial tuberosity with the fingers

monitoring motion at the SIJ.- The dysfunctional innominate is taken to the barrier in flexion, external rotation, and

abduction (engagement of the barrier and loose-packing the SIJ).- Physician exerts a cephalward and lateral force on the ishial tuberosity. The

physician resists three to five efforts of three to five second muscle effort for the patient to extend the leg against resistance.

- The physician takes-up the “slack” and repeats this process until proper release is obtained.

- Retest

Posterior Innominate Rotation

- Type of ME: Joint mobilization using muscle force- Patient may complain of inguinal/groin pain (secondary to rectus femoris dysfunction)

and/or medial knee pain.- Patient is supine with the physician standing on the same side as the dysfunction.- The patientʼs sacrum is brought to the edge of the table (freeing the SIJ).- The patientʼs leg is placed off the table while the pelvis is supported with a hand

placed over the contralateral innominate.- Physicianʼs other hand is placed over the distal femur above the patella to push the hip

toward anterior rotation.- Physician resists patientʼs effort to flex the hip through a series of contractions of

three to five seconds, 3-5 times.- Retest


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Outflare Innominate (Externally Rotated)

- Type of ME: Post Isometric Relaxation- Patient is supine with the physician standing on the same side as the dysfunction.- Physician flexes the hip and knee rolling the pelvis to the opposite side.- Physician monitors the medial side of the PSIS and then the pelvis is brought back to

the table to rest on the physicianʼs monitoring hand.- Physicianʼs other hand adducts the femur to the internal rotation barrier while

maintaining lateral traction on the PSIS.- Patient attempts to abduct and externally rotate the hip with three to five muscle

contractions for three to five seconds with the slack in the tissues taken up between the contraction intervals.

- Retest

Inflared Innominate (Internally Rotated)

- Type of ME: Post Isometric Relaxation- Patient is supine with the physician standing on the same side as the dysfunction.- The patientʼs hip and knee is flexed with the ipsilateral foot placed on the contralateral

knee (below patella).- Physician places one hand over the contralateral innominate to stabilize the pelvis and

places the other hand over the medial side of the knee on the dysfunctional side, externally rotating the hip until a barrier is engaged.

- The physician resists three to five efforts of three to five second muscle contractions for the patient to internally rotate the leg against resistance, taking up the slack in the tissues between the contraction intervals.

- Retest


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Sacral Mechanics in Sacroiliac Dysfunction: Muscle Energy Model

Objectives

- Identify and differentiate Mitchell model ME tests and landmarks, their biomechanical basis and results.

- Given the appropriate diagnostic information, the student will derive and identify the correct muscle energy model sacroiliac diagnosis.

Models of Sacroiliac Somatic Dysfunction

- Why do we use models?- To try to more simply understand complex processes- To better define a diagnosis

- Why are there different models?- HVLA, ME, OCF, Still

- Why do we use them when we know theyʼre not perfect?- Because they give predictable results when we use them for treatment

Todayʼs Model is the Muscle Energy Model

- Developed by Fred Mitchell, Sr., D.O.- Based his ideas on the normal physiologic motion of the walk cycle, plus function and

dysfunction involved in twisting and bending while in flexion and extension- He called these problems sacroiliac dysfunctions- They involve dysfunction at either:

- the sacroiliac joint(s)- the L5/S1 joint

To Determine Whether There Is Sacroiliac Somatic Dysfunction:

- Perform three tests- Seated flexion- Spring- Backward bending

- Examine two landmarks- Sacral sulcus- Inferolateral angles of the sacrum (ILAs)

- To diagnose two problems- Sacral shears

- 6 possible diagnoses- Sacral torsions

- 4 possible diagnoses

Block 4 OPP Notes! Sacral Mechanics in Sacroiliac Dysfunction: ME

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Putting the Puzzle Together to Make a Sacral Diagnosis

- Motion Testing- Seated flexion test

- Which PSIS goes the farthest at the end- range of motion?- Spring test

- Is there good lumbosacral spring, or poor spring?- Backward bending test (Sphinx test)

- Do sacral landmark findings improve, or become more asymmetrical when backward bending is introduced?

- Static (Pure) Landmarks- Sacral base at the sulcus (sulci)

- Which side is anterior or deep?- ILA •#Which side is posterior and inferior?

- And then, determine:- L5 rotation

The oblique axes are used in the gait cycle

Sacral Sulcus

- Determine by visualization and palpation which aspect (left or right) of the sacral sulcus is deeper and which more shallow

- Find the PSISs- Curl your thumb pads medially over them to palpate the lateral aspects of the

two sacral sulci- Determine the depth from the most posterior aspect of the PSIS to the base of

the sacrum- Decide which is deeper and which is more shallow

- You will repeat this observation later during the backward bending test

Inferolateral Angles of the Sacrum (ILAs)

- Determine by visualization and palpation which (left or right) is posterior and inferior- Patient is prone- Push thumb pads against posterior inferolateral aspects of ILAs- You will repeat this observation later during the backward bending test


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Three Tests

- Seated flexion- If this test is positive, thereʼs a sacroiliac dysfunction

- Backwardbending (sphinx)- Spring

Seated Flexion Test

- Patient is seated, with feet on the floor or supported on the rung of a ladder back stool.- Place your thumb pads on the inferior aspects of the PSISs.- Ask the patient to bend forward, allowing the elbows to pass between the knees.- The side which is forward at end of range of motion is positive.

Seated Flexion Test (Seated Forward Bending Test)

- If the problem is a sacral shear- the positive side tells you the side of the dysfunction- A positive left seated flexion test means that there is either

- a left unilateral flexion- a left unilateral extension

- If the problem is a sacral torsion,- the positive side is opposite to the side of the oblique axis.- A positive left seated flexion test means that if there is a sacral torsion, the

sacrum has a right oblique axis.

Spring Test

- Patient is prone- Place your cephalad hand on the lumbar spine with the thenar eminence over

L4 and the superior edge of L5- Reinforce this with your caudad hand, and induce a forward springing motion to

the lumbosacral junction- Is there good spring, or poor spring?

- If the sacrum is held forward on one side, or is normal,both sides can spring forward. This will produce good spring (a negative spring test).

- If the sacrum is held backward on one or both sides, it cannot spring forward and so will have poor spring (a + spring test).

- Experience gives you more reliable results (the test seems very subjective, but over time, you develop a more extensive internal system of reference for how to interpret the results).


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Backward Bending Test

- Often nicknamed the sphinx test or tv position- Done after you have determined your initial findings for the sacral sulcus and

ILAs- Have the prone patient bend backward and lean on the elbows- Re-examine the sacral sulcus and ILAs

- During backward bending,- the sacral base moves anteriorly- as the body bends backward around the L5/S1 joint

Improved (More Symmetric) Findings On the Backward Bending Test

- Normally, both sides of the sacral base move forward during backward bending- If one side is held forward, it can still move even farther forward; the other side

will also move forward during backward bending- Findings will therefore improve

- If the sulcus and ILA findings were asymmetrical, but improve with backward bending, the sacral base is being held forward on one side. This indicates two possible diagnoses:

- Anterior torsions (L/L, R/R)- Unilateral flexions (L, R)

Worse (More Asymmetric) Findings On the Backward Bending Test

- When dysfunction holds one side backward, the non-dysfunctional side will still move forward during backward bending

- Landmark findings will therefore look more asymmetric (worse!)- If findings look worse (more asymmetric), then the sacral base is being held backward

on one side. This indicates two possible diagnoses:- Posterior torsions (L/R, R/L)- Unilateral extensions (L, R)


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Two Classes of SI Diagnoses

- Sacral shears- Non-physiologic- True SI joint dysfunction- Involve slippage of the sacrum around the backward C-shaped SI joint- Occurs around the middle transverse axis

- Sacral torsions- L5/S1 joint problem- Involve imbalance in the muscles that affect sacral motion in relationship to L5

motion, and also the piriformis muscle- Occurs around oblique axes

Two Problems, 10 Diagnoses

- Sacral shears- Left unilateral flexion- Right unilateral flexion- Left unilateral extension- Right unilateral extension- Bilateral flexion- Bilateral extension

- Sacral torsions- Anterior sacral torsions

- Left rotation on left oblique axis (L/L ST)- Right rotation on right oblique axis (R/R ST)

- Posterior sacral torsions- Right rotation on left oblique axis (R/L ST)- Left rotation on right oblique axis (L/R ST)

You Examine the ILAs and Sacral Sulcus, and Find:

- Sacral shear- The deep sulcus and posterior, inferior ILA are on the same side.- A unilateral relationship

- Sacral torsion- The deep sulcus and posterior, inferior ILA are on opposite sides. - A diagonal relationship


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How Do You Name a Sacral Shear?

- Four types, six diagnoses:- Unilateral flexion

- Left, right- Unilateral extension

- Left, right- Bilateral flexion- Bilateral extension

- Unilateral shears are named for:- The side of the positive stead flexion test- Whether the sacral base on that side is flexed (deep) or extended (shallow)

- E.g., right unilateral sacral flexion- Bilateral shears

- Bilateral sacral flexion- Bilateral sacral extension

Left Unilateral Sacral Flexion

- + Left seated flexion test- Deep sacral base on left- Posterior, inferior ILA on left- Good spring- Findings improve on backward bending test- L5 rotated left

Right Unilateral Sacral Flexion

- + Right seated flexion test- Deep sacral base on right- Posterior, inferior ILA on right- Good spring- Findings improve on backward bending test- L5 rotated right

Left Unilateral Sacral Extension

- + Left seated flexion test- Deep sacral base on right- Posterior, inferior ILA on right- Poor spring- Findings worse on backward bending test- L5 rotated right


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Right Unilateral Sacral Extension

- + Right seated flexion test- Deep sacral base on left- Posterior, inferior ILA on left- Poor spring- Findings worse on backward bending test- L5 rotated left

How Do You Name A Sacral Torsion

- You have to determine the oblique axis- It is opposite to the side of the + seated flexion test

- + right seated flexion test = Left oblique axis- + left seated flexion test = Right oblique axis

- Then decide to which side the sacrum is rotated around that axis- Forward torsions: the sacral base rotates forward around the axis

- Left rotation around a left oblique axis (L/L)- Right rotation around a right oblique axis (R/R)- As with the vertebrae, the side of the rotation is the side toward which

the anterior portion of the sacrum faces- Backward torsions: the sacral base rotates backward around the axis

- Right rotation around a left oblique axis (R/L)- Left rotation around a right oblique axis (L/R)

Left Rotation on Left Oblique Axis L/L ST

- + Right seated flexion test- Sacral sulcus:

- deep on right - (sacral base rotated left)

- ILA: - left is posterior/inferior

- Backward bending test: findings improve (more symmetrical)- Good spring - L5 is rotated right


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Right Rotation on Left Oblique Axis R/L ST

- + Right seated flexion test- Sacral sulcus: deep on left (sacral base rotated right)- ILA: right is posterior and inferior- Backward bending test – findings worse- Poor spring - L5 rotated left

Right Rotation on Right Oblique Axis R/R ST

- + Left seated flexion test- Sacral sulcus: deep on left (sacral base rotated right)- ILA: right is posterior and inferior- Backward bending test: findings improve (more symmetrical)- Good spring - L5 rotated left

Left Rotation on Right Oblique Axis L/R ST

- + Left seated flexion test- Sacral sulcus: deep on right (sacral base rotated left)- ILA: left is posterior and inferior- Backward bending test – findings worse- Poor spring - L5 rotated right


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Bilateral Sacral Shear Dysfunctions

- No positive seated flexion test- Landmark findings are symmetrical- Bilateral sacral flexion

- Increased lumbosacral angle- Increased lumbar lordosis- Sacral sulcus is deep on both sides

- Even more so with backward bending- ILAs are both posterior

- Even more so with backward bending- Good spring

- Bilateral Sacral Extension- Decreased lumbosacral angle- Decreased lumbar lordosis- Sacral sulcus is shallow on both sides

- Even more so and often with pain on backward bending- ILAs are both anterior

- even more so with backward bending, but patient often wonʼt do it.- Poor spring


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- Note - L5 is rotated to the same side as the deep sulcus

SI DIagnostic Sequence

- Seated flexion test - Tells you if thereʼs a sacroiliac problem- Spring test - Tells you whether the sacral base is held forward or backward- Sacral sulci and ILAs - The landmarks tell you toward which side the sacrum is rotated,

or whether it is flexed or extended- Backward bending test (sphinx) - Tells you whether the sacral base is held forward or

backward


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Muscle Energy: Sacral Shears and Torsions

Objectives

- Sacral Shears (non-physiologic)- Unilateral sacral flexion

- Left- Right

- Unilateral sacral extension- Left- Right

- Bilateral sacral flexion- Bilateral sacral extension

- Sacral torsions (physiologic)- Anterior torsion

- Left on left sacral torsion (L/L)- Right on right sacral torsion (R/R)

- Posterior torsion- Left on right sacral torsion (L/R)- Right on left sacral torsion (R/L)

Respiratory Motion

- Inhalation - Curves flatten, sacrum counternutates- Exhalation - sacrum nutates

Block 4 OPP Notes! Muscle Energy - Sacral Shears and Torsions

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Bilatereal Sacral Shear Dysfunctions

- No positive seated flexion test- Landmark findings are symmetrical- Bilateral sacral flexion

- Increased lumbosacral angle- Increased lumbar lordosis- Sacral sulcus is deep on both sides

- even more so with backward bending- ILAs are both posterior

- even more so with backward bending- Good spring

- Bilateral sacral extension- Decreased lumbosacral angle- Decreased lumbar lordosis- Sacral sulcus is shallow on both sides

- even more so and often with pain on backward bending- ILAs are both anterior

- even more so with backward bending, but patient often wonʼt do it.- Poor spring

Sacral Shears

- Abduct the leg(s) about 15° to gap the SI joint. - Flexion shears

- Internally rotate the hip(s) [gaps posterior SI]- Extension shears

- Externally rotate the hip(s) [gaps anterior SI]

Bilateral Sacral Flexion

- Abduct both legs to about 15° to disengage the SI joints.- Internally rotate both hips to further gap the posterior SI joint.- Place the heel of your hand on the central portion of the apex of the sacrum, pressing

anteriorly.- Augment counternutation during inhalation to bring the sacral base posterior and

superior; resist nutation during exhalation.- Repeat for a total of 3-5 cycles.- Retest.


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- + Left seated flexion test- Deep sacral base on left- Posterior/inferior ILA on left- Good spring- Findings improve on backward bending test- L5 rotated left


- Monitor the sacrum at the middle transverse axis as you abduct the left leg to about 15° to disengage the SI joint.

- Internally rotate the hip to further gap the posterior SI joint.- Place the heel of your hand on the left ILA, pressing anteriorly.- Augment counternutation during inhalation; resist nutation during exhalation.- Repeat for a total of 3-5 cycles.- Retest.

Right Unilateral Sacral Flexion

- + Right seated flexion test- Deep sacral base on right- Posterior/inferior ILA on right- Good spring- Findings improve on backward bending test- L5 rotated right

Left on Left (L/L) Sacral Torsion

- Patient starts in the prone position with arms off the table toward the floor. - Bend the patientʼs knees and hips to about 90° and roll onto the left hip (side of axis,

down) into the left modified Sims position.- Monitor the lumbosacral junction with your left hand, while your right hand rotates the

upper trunk to rotate L5 to the left. - Physician is seated behind the patient as shown here, the left hand monitors the sacral

base while the right hand guides left sidebending until the sacral base starts to move posteriorly to the right.


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Left on Left (L/L) Sacral Torsion

- When the restrictive barrier is fully engaged, have the patient attempt to lift the legs toward the ceiling (right hip abductors, gluteii, piriformis) for 3 to 5 seconds while you resist this movement.

- This is followed with a 2 second pause/relaxation phase.- Take up the slack until the next left sidebending and left rotation restrictive barrier is

engaged.- Repeat for a total of 3-5 cycles.- Retest.

Right Rotation on Right Oblique Axis R/R ST

- + Left seated flexion test- Sacral sulcus:

- Deep on left (sacral base rotated right)- ILA:

- Right is posterior and inferior- Backward bending test:

- Findings improve (more symmetrical)- Good spring- L5 rotated left

Right Rotation on Left Oblique Axis R/L ST

- + Right seated flexion test- Sacral sulcus:

- Deep on left (sacral base rotated right)- ILA:

- Right is posterior and inferior- Backward bending test - findings worse- Poor spring- L5 rotated left


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Left on Right Sacral Torsion (L/R)

- Patient is right lateral recumbent (side of the axis down).- Monitor the lumbosacral junction with your right hand; pull the patientʼs right arm with

your left hand in a caudal and anterior direction until you feel L5 rotate to the left.- Extend both legs until the sacral base just begins to move anteriorly.- Bring the left leg in front of the right knee and place your right hand on the distal femur

(or lower leg) for leverage.- Maintain the L5 rotation with your forearm on the shoulder while the patient lifts the left

leg to the ceiling against your resistance.- When the restrictive barrier is fully engaged, have the patient attempt to lift the legs

toward the ceiling for 3 to 5 seconds while you resist this movement. - This is followed with a 2 second pause/relaxation phase.- Take up the slack until the next restritive barrier is engaged.- Repeat for a total of 3-5 cycles.- Retest.

Left Rotation on Right Oblique Axis L/R ST

- + Left seated flexion test- Sacral sulcus:

- Deep on right (sacral base rotated left)- ILA:

- Left is posterior and inferior- Backward bending test:

- Findings worse- Poor spring- L5 rotated right

General Comparisons Between Lumbar and Sacral Treatment Positioning in Muscle Energy Techniques

- Left on left (L/L) starts like ERS right- Right on right (R/R) starts like ERS left- Left on right (L/R) starts like FRS right- Right on left (R/L) starts like FRS left


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Sacral Somatic Dysfunction

- Diagnosis typically requires two pieces of information:- The relative position of the two sacral sulci and the two inferior lateral angles

(ILAs). - The two sulci are designated as feeling either deep or shallow compared

with each other. - ILAs are designated as being posterior/inferior or anterior/superior

relative to each other. - Unilateral sacral dysfunction

- The deep sulcus and the posterior/inferior ILA are on opposite sides of the sacrum, you have torsion

- The deep sulcus and the posterior/inferior ILA are on the same side of the sacrum, you have unilateral sacral flexion (shear) or extension

- A motion test- Lumbar spring test

- Patient is prone- Spring force is directed anteriorly into the lumbar spine- Normal spring

- Indicates presence of an anterior torsion or a unilateral flexion

- Increased resistance to pressure- Indicates presence of either a posterior torsion or a

unilateral extension.- Sphinx test

- Also called lumbopelvic hyperextension- Observe changes in asymmetry at the sacral sulci- When going from the prone position to the sphinx position:

- If the sacral sulci become more symmetric, anterior torsion or unilateral flexion

- If the sacral sulci become more asymmetric, posterior - torsion or unilateral extension

- Seated flexion test- Patient is seated on a low stool or side of a treatment table with

feet touching the floor- Physician stands or kneels behind the patient with his eyes at the

level of the PSISs- The physicianʼs thumbs are positioned on the inferior slopes of the

PSISs- The patient is instructed to bend forward as far as possible- Positive test

- One PSIS moves more cephalad by at least one thumb breadth at the end of the range of motion

- Potential dysfunctions include anterior and posterior torsion, and unilateral flexed and extended sacra


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- Seated assessment of ILA asymmetry- Similar to seated flexion test, but the ILAs are monitored- If asymmetry increased, posterior torsion or unilateral

extension- If asymmetry decreases or stays the same, anterior torsion or

unilateral flexion- Four-digit contact

- Contact the four corners of the sacrum- Assess motion of the sacrum by direct pressure on the sacrum,

moving it about its various axes, or quietly palpate sacral motion while the patient respires


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Block 4 OPP Lecture Notes

Documents

Transcript of Block 4 OPP Lecture Notes