OMM for the pregnant patient Stuart Williams do, chairman and associate professor, Omm Chairman & Associate Professor Osteopathic Manipulative Medicine

Objectives Describe the physiological and structural changes in normal pregnancy. Define the application of OMM (physiologic models) as they pertain to the obstetrical patient. Review the autonomic nervous system as it pertains to the tenant of osteopathy: structure and function are interrelated. Recall the common complaints of an obstetric patient and explain an Osteopathic approach. Review the diagnosis and treatment of the Lumbar spine, Pelvis, and Sacrum as it would apply to a pregnant patient.

Objectives Discuss and practice OMT techniques helpful for obstetrical patients with: Edema Low Back Pain

References Foundations of Osteopathic Medicine, 3rd Ed, 2011, Anthony Chila D.O., P 961-973. Somatic Dysfunction in Osteopathic Family Medicine, Nelson, Glonek, 2007, P 108-125. Osteopathic Considerations in Systemic Disease, Revised 2nd Ed, Kuchera & Kuchera, P 149-158.

Common Complaints Edema (esp LE swelling) LBP IVC pressure increases Usually pelvic, innominate, and sacral pain Lumbar discomfort as well As preggers become more pregger  more lordosis  sacrum anterior and strain of iliolumbar ligaments Can create leg pain and sclerotomal plain May tell you they have discomfort along the lateral thigh or into groin On ave  pts get 7deg more lordosis  reset the center of gravity so Pts try to balance lordosis by becoming more kyphotic (usually by about 6 deg) leaning forward  rib pain Get lower extremity swelling due to: IVC pressure  more fluid in 3rd space If bp up, pt has a little bit of proteinuria  lay on L side and recheck bp

Differential for LE Swelling Varicosities  get exaggerated because of the pressure Passive vascular congestion Preeclampsia Lymphedema Thrombophlebitis  bc pregnancy is a hypercoaguable state DVT Cellulitis  more predisposed bc lymphatics are clogged up UTI  ureters dilate during pregnancy Somatic Dysfunction Wind (lungs, atelectasis), water (UTIs), walk (DVTs), wound infection, wonder drugs (serum sickness from a cephalosporin or something like that)

Differential Dx for LBP in Pregnancy Spinal facet Spondylolisthesis Leg-length inequality Congenital Overweight Multiple gestations Trauma Discogenic Scoliosis Ligamentous laxity Somatic dysfunction Difficult to differentiate between nerve root discomfort, myelopathy pain, and spinal facet discomfort National ave of leg length inequality = 3/16 of an inch Remember lordosis and kyphosis get exaggerated during pregnancy (kyphosis because of compensation)  can make scoliosis worse Spondylolisthesis Slippage of one vertebrae on top of another Causes sagittal plane issues  causes more of a lordosis and makes their lordosis that is already exaggerated because of pregnancy much worse Discogenic pain Around age 30 start loosing blood supply to the disc  narrows the disc (which all together they make up about the 4th of their height) Preggers also have lots of relaxin  can create more Ligamentous laxity issues localizing to fix an issue

Differential Dx cont. Viscerogenic Vascular Urinary tract compression of gr v. Bowel function venous plexopathy Endometriosis thrombosis Pelvic Infection placental location Labor Will see hemorrhoids  because inc in pressure on IVC Pregnancy will slow down peristalsis Need a stool softener a lot of the times In general, endometriosis will get better during pregnancy, but if they have a lot of implants then they can have issues during pregnancy A lot of times when a woman is in labor, they complain of back pain more than contractions depending on where the baby is positioned

Changes in Pregnancy Center of Gravity Affects both: Posture – lordosis tips sacrum forward LBP Gait Both Joint motion restrictions and hypermobility! Pressure from expanding uterus Decreases venous and lymphatic drainage esp from dependent areas (LE) Edema Posture  will compensate lordosis with an anterior sacrum and exaggerating kyphosis as well to get their center of gravity Will see a waddling gait  can cause issues in the SI and innominate issues from this Both Joint motion restrictions and hypermobility can make a successful tx difficult  rely on many indirect techniques with pregnant women

Somatic Dysfunction in Pregnancy Compensated m/s imbalances while nonpregnant may decompensate during gestation Somatic Dysfunction Ex: A scoliosis that may not have bothered a patient may become more uncomfortable We all have compensated musculoskeletal (m/s) imbalances that we compensate, but then when pregnant can cause more issues = Exaggerations of Normal (physiologic exaggerations) KNOW THIS (this goes with what is stated in red) Remember that relaxin is not specific and will relax everything, not just the pelvic bones

Physical Examination Observation Palpation ROM (screening) Muscle Imbalances DTRs Posture Degree of lumbar lordosis ROM – most has to be done seated, some can be done supine Muscle imbalance ex – an innominate stuck anteriorly can be the result of this DTRs Deep tendon reflexes  you’re trying to watch out for preeclampsia Tx = deliver the baby Posture Sagittal plane gets exaggerated in pregnancy Normal ferguson’s angle = angle of the incline drawn with the horizontal at L5 - Normal is 30 – 40 deg  45 to 50 deg in pregnancy

Contraindications to OMT in Pregnancy Undiagnosed vaginal bleeding Ectopic pregnancy Placental abruption Untreated DVT Elevated maternal BP Preterm labor Unstable maternal VS Fetal distress

“Only one report has been published concerning complications of direct manipulation in the pregnant patient.” Foundations of Osteopathic Medicine, 3rd Ed, 2011. Direct Techniques can be utilized in the pregnant patient. Harder to reach your barrier - Not as much as a thrust as a gentle tug

Edema Goal: efficient and effective venous and lymphatic drainage Areas of Restriction to flow to address: Craniocervical Junction Thoracic Inlet (Greatest flow of restriction) Thoraco-abdomenal Diaphragm Pelvic Diaphragm (LE edema) Methods to augment the flow of fluids: 3rd space, lymph Diaphragm – just a restriction of flow

Lab objectives Explain and demonstrate an Osteopathic approach OMM to treat edema in pregnancy as presented in lab and lecture. Discuss and exhibit both direct and indirect OMM techniques taught in lab for low back pain in pregnancy.

Seriously williams…..seriously?!

Plantar Fascia This is considered a restriction to flow (diaphragm)

This is on the OMM practical Crisscross thumbs and push in a superior and lateral fashion at the same time Must get through all 3 layers of fascia - Have the pt dorsiflex (tell them to extend the toes) until you feel tension, hold it until you feel the tension release (may take 10 sec or so )  have them put their foot in a neutral position, repeat by taking slack up, and then have them curl their toes, do it again Apply a superolateral force to each layer of fascia in: 1. Toes extended. 2. Toes in neutral. 3. Toes in flexion. Wait for a release during each phase. Recheck. Remember that a lot of low back pain has to deal with lower extremities

Interosseous Membrane

Interosseous Membrane This is considered a diaphragm as well Vessels and nerves here As well as lymphatic and arterioles The membrane acts as Dural sheath around this Remember that when you sprain your ankle it can transmit all the way up the membrane  pt will complain of “knee pain” when it is really their fibular head Most common way to sprain the ankle Plantar flex, invert, and Adduction  fibular head comes posterior bc distal fibula goes anterior If you evert, dorsiflex, and Abduct  fibular head comes anterior bc distal fibula does posterior This stuff all sounds like a Dr. Williams question to me…I’d know this slide well.

Fibular Head and Interosseous Membrane Technique: Supine Direct Ligamentous Articular Release Findings: Posterior and lateral knee pain or unstable ankle with chronic spraining of the ankle. The latter is a result of an unstable ankle mortise with the fibula displaced at the knee. Pt is supine and Physician is seated facing the side of the table at the level of the affected knee . This is on the practical Landmark  find tibal tuberosity and then move over laterally to find the fibula head “feels like a taffy pull” - Do this first before other leg techniques Diagnostic findings: Tissue texture changes anywhere between fibula and tibia One or both ends of the fibula restricted Ankle function may be impaired Tenderness at proximal tibiofibular joint, distal tibiofibular joint and/or ankle

Fibular Head and Interosseous Membrane Treatment. Flex the hip and the knee to 90 deg. Slightly externally rotate the femur With the cephalad arm, bend elbow to 90 deg and prop it on the table making a pedastal out of your forearm and thumb. With the pad of the thumb push the posterior superior portion of the fibular head inferiorly toward the pt’s foot. The distal hand inverts and slightly medially rotates the foot. A release occurs when the fibular head moves inferiorly and anteriorly and slides back into the socket. Need to externally rotate the leg at the hip and invert the foot (know this for lab)

Popliteal Fascia This is considered a diaphragm as well

Direct MFR: Popliteal Fascia Technique: supine, direct, MFR Findings: Pain behind the knee or baker’s cyst. Physician: Seated at the side of the table inferior to the patient’s knee, facing the head of the table. Let the weight of the knee rest on your fingertips  applying an anterior force, and then start to apply an inferior distraction (know this for lab) A baker’s cyst is so named because baker’s who stand in one place for hours at a time for days and years can end up with a bursal swelling in the popliteal fascia. Obviously this would apply to anyone whose lifestyle involved similar conditions.

Direct MFR: Popliteal Fascia Procedure: With the patient’s leg relaxed place your fingertips just above the popliteal fossa. Fingers of both hands are bent with the fingernails of the two hands facing each other and thenar eminences about 3” apart to form a “plow” shape. Press anteriorly just superior to popiliteal fossa. Draw the fingers inferiorly until resistance is felt, then hold until the release occurs.

I totally ate the slide of that orange dream cake with Sarah before anyone else got there. Sorry bout it.

Pelvic Diaphragm

Ischiorectal Fossa Release and Dome Pelvic Diaphragm Distention of the pelvic diaphragm must be in phase with the continual movements of the thoracic diaphragm and also with the transient changes in intrapelvic pressure This aids in free flow of fluids within the vascular and lymphatic channels of the pelvic region We won’t do this in lab as was done in Dr. Alsip’s. Pages 56-58 in the Kimberly Manuel

Ischiorectal Fossa Release and Dome Pelvic Diaphragm Lymphatic flow depends on elasticity of the pelvic floor The pelvic floor must compensate for respiratory pressures and the transient increase of pressure caused from coughing, sneezing, hiccups, pregnancy etc A rigid pelvic floor leads to dysfunction If you are sitting on the same side as the side you are going to treat then you need to aim superiorly and laterally with your fingers You can also sit on the opposite side you want to treat and use your thumb to treat (still superior and lateral force…seethe next slide)

Pelvic Region Ischiorectal Fossa Release, Supine The patient lies supine with the hips and knees flexed. The physician sits at the side of the table opposite the side of the dysfunction to be treated. The physician places the thumb of the hand closest to the table medial to the ischial tuberosity (arrow, Figs. 16.80 and 16.81) on the dysfunctional side. The physician exerts gentle pressure cephalad (arrow, Fig. 16.81) into the ischiorectal fossa until resistance is met and then applies a lateral force (curved arrow, Fig. 16.82). The physician can attempt to feel a fluid ebb and flow with a resultant release or add a release-enhancing mechanism by instructing the patient to inhale and exhale deeply. With each exhalation, the physician exerts increased cephalad pressure on the pelvic diaphragm until no further cephalad and lateral excursion is possible. This technique is repeated on the opposite side of the pelvis as needed 16.80 16.81) Fig. 16.82).

Pubic Decompression

PUBIC COMPRESSION/ DECOMPRESSION Compression of Pubic Symphysis pubic bones are forced toward each other at the pubic symphysis Characteristic Findings tender over symphysis bilaterally. lack of apparent asymmetry. restriction of motion at pubic ring. ASIS springing affected bilaterally Note: Pubic shears are usually associated with pubic compression. It’s a good idea to decompress the pubic bones prior to treating a shear. When you walk the pubes do move, and so when preggers, you’ve now got relaxin and this can cause these to move even more when yu walk

PUBIC DECOMPRESSION- MUSCLE ENERGY 1. Pt. supine on table, knees and thighs flexed. 2. Feet flat on table 10-12 inches apart. 3. Grasp both knees. “Try to pull your knees apart.” (abductor muscles pull laterally on innominate compressing the symphysis further to prepare it to relax.) 4. Repeat. 5. Heel of one hand in knee, posterior distal humerus in other knee. 6. Knees 10 to 12 inches apart. “Try to pull your knees together.” 7. Repeat . (av. 3 times) Also good to do with UTIs

Brings them together to compress the pubic symphysis a little bit more so when you do the opposite you can bring them open(see the next slide)

Separates them

Innominate Rotations

INNOMINATE ROTATION Innominate: 3 fused bones ilium ischium pubis Articulations: innominates femur at acetabulum sacrum at SI joint pubic bones articulate with each other at symphysis. Do lateralizing tests 1st to determine side of somatic dysfunction: ASIS compression test, standing flexion, seated flexion.

ANTERIOR INNOMINATE ROTATION Def: one innominate will rotate anteriorly compared to the other. - tight quadriceps Diagnostic Findings: ex: Right Anteriorly Rotated Innominate ASIS more inferior on R PSIS more superior on R Right sulcus shallow Right sacrotuberous ligament loose Right medial malleolus may be inferior AP compression test restricted on R + standing flexion test on R + sitting flexion test on R

ANTERIOR INNOMINATE ROTATION SUPINE MUSCLE ENERGY Ex: Right Anterior Innominate: 1. Pt. supine & D.O. on side of dysfunction. 2. Flex lower extremity on side of dysfunction at knee and hip.( no abduction as in shear and flare). 3. Put shoulder against pt’s leg & cup ASIS with cephalad hand & ischial tuberosity with caudad hand. 4. Hold tension at all points until innominate rotates posteriorly to restrictive barrier. 5. “Push knee against my chest.” 6. Sense that force is localized at SI joint. 7. Wait 3-5 seconds. 8. Flex hip and rotate innominate posteriorly to new restrictive barrier. 9. Repeat until best motion. (usu. 3 times). Recheck.

You need to think of yourself as one unit when you are doing this

INNOMINATE POSTERIOR Def: one innominate will rotate posteriorly compared to other. (remember to lateralize: ASIS compression, Standing and Seated flexion tests). Physical Examination: ASIS superior on involved side. PSIS more inferior on involved side. medial malleolus may be superior AP compression restricted on involved side. + standing flexion test on involved side. + sitting flexion test on involved side sacrotuberous ligament tight on involved side. tender over SI joint.

INNOMINATE POSTERIOR SUPINE MUSCLE ENERGY EX: Left Posterior Innominate 1. Pt. supine & D.O. on side of somatic dysfunction. 2. Pt. on edge of table allowing ischial tuberosity to be off edge. 3. Leg hangs freely. 4. Cephalad hand reaches across & stabilizes opposite ASIS. 5. Tension applied to ant. thigh rotating innominate anterior to new restrictive barrier. (D.O. leg on outside of pt’s leg). 6. “Pull your knee up to the ceiling.” 7. Sense that contractile force is localized to SI joint. 8. Extend extremity to new restrictive barrier. 9. Repeat until best motion obtained. ( usu.. 3 times.) 10. Recheck.

Leg is against the table, not gapping symphysis unless needed to (know that) Brace the opposite ASIS so they don’t feel like they are going to fall off the table

Soft Tissue

And for the 1000th time……

1001th….

LUMBAR REGION-MUSCLE ENERGY LUMBAR NEUTRAL SEATED-DIRECT METHOD – MUSCLE ENERGY Lumbar neutral, side-bending left, rotation right 1.Patient straddles the end of the table and the physician stands to the left and behind the patient 2.Patient’s right hand is placed on his/ her left shoulder 3.Physician reaches across the patient’s chest with his/her left hand, grasps right shoulder of arm, and leans against the patient’s left shoulder 4.Physician places the pad of his/her right thumb on the TP of the dysfunctional segment to monitor motion and provide a fulcrum 5.Physician induces varying increments of left rotation, right side-bending, and flexion or extension until there is full engagement of the restrictive barrier. Keep the patient upright and balanced Under over for neutral Salute the side of rotation

LUMBAR REGION-MUSCLE ENERGY 6.Patient is instructed to “bend to the left against me” 7.Patient maintains force for 3-5 seconds 8.Patient is instructed to relax 9.Physician waits about 2 seconds and then repositions all planes to the new restrictive barrier 10.Repeat 3-4 times 11.Recheck

This is noted in the lab info I posted too, but know: You sit on the same side as the pts rotation diagnosis (opposite the sidebending diagnosis) Flex the legs by bending the knees and putting the pts feet on the table (this helps flatten the lordosis) Pull their ankles towards you (creates opposite side bending of their diagnosis) and at the same time reach across the spinous process and pull it towards you (creates rotation opposite the diagnosis)

Sacrum Just read what I have written below slides and then go to mulroy’s powerpoint….he makes it crystal clear

Sacral Base Anterior Name: Sacral Base Anterior, Bilateral Sacral Flexion Lateralization: Does NOT matter. Spring test: Negative Landmarks: Sacral Base: Bilaterally (B/L) Anterior Sacral Sulcus: B/L Deep ILA: B/L Posterior STL: B/L Tight Motion: Sacral Base: B/L + ILA: B/L – Ant + Ant+ Deep Deep Post - Post- Remember that the more lordodic you are, the more the sacrum moves anterior A negative spring test = moves well + spring test = feels like a brick This will cause a stress on the ILA (which will feel like a brick bilaterally) and cause a stretch on both of the sacrotuberous ligaments (tight, posterior) superior transverse axis = respiratory axis Sacroilial motion - 2nd axis 3rd axis – for innominate movement (the iliosacral) - I could see him testing on this Just a side note – when you do a seated flexion test – testing sacroiliac, and when doing standing flexion test testing iliosacral motion …I’d know that too

If you get williams, and you get the sacrum with a bilat anterior sacrum….I’m gonna bet you’re going to get this for the practical

Vertical Axis Diagnosis: less common Name: Left Sacral Margin Posterior Lateralization: Matters NOT. Always call on Posterior side. For Left Sacral Margin Posterior: Landmarks: data recorded on lateralized side Sacral Base: L Posterior Sacral Sulcus: L Shallow ILA: L Posterior STL: L Tight Motion: Sacral Base: L – R + ILA: L – R+ Shallow P – A+ Deep P - A+ This is on the practical too Don’t see much inferior posterior with the ST ligament How could we treat this?

*Also used for lumbar SD, “OB Roll” Patient would be rotated to the level of the somatic dysfunction at the lumbar spine. In the above case, the patient would be NSRRL as you are rotating the patient to the Right to correct the rotational component. By pushing the patient’s shoulders and legs away from the D.O., you are creating Sidebending Left. My note: You need to stand on the opposite side of the posterior sacrum You need to pull their hips towars you You are applying a thrust to the hip (not yanking them up by their upper extremity with your arm….that is just to localize) on the same side as the sacrum that is posterior. - You know the sacrum moves opposite the innominate and the lumbar so the theory is that when you push that innominate posterior, it allows the sacrum that is dysfunctionally posterior to move anteriorly

Sacral Diagnosis L R Named for upper pole of sacrum Forward Torsion Neutral Rotation in same direction Left rotation on left oblique axis Right rotation on a right oblique axis Backward Torsion Non-neutral Rotation in opposite direction Right rotation on left oblique axis Left rotation on a right oblique axis L R The arrows are all funny on this to me…..don’t like this pic. Just go look at Mulroy’s lect and listen to his sacral info.

Left Neutral Sacral Oblique Axis Somatic Dysfunction Name: L on LOA, RL on LOA, L Forward Torsion Landmarks: if calling findings on L side Sacral Sulcus: L Shallow Sacral Base: L Posterior ILA: L Post./ Inf. STL: L Tight Motion Testing: Spring: - (It springs easily!) Sphinx: - (improves with extension) L5: NSLRR Sacral Base L - R + ILA: L +/- R +/- note: Seated Flexion test may be + on R with this dysfunction (confirmatory) L5: SLRR P - A + +/- P+/- A Left Right Midline

Right Neutral Sacral Oblique Axis Somatic Dysfunction P+/- A+ L5: SRRL Name: R on ROA, RR on ROA, R Forward Torsion Landmarks: if recording findings on R side Sacral Sulcus: R Shallow Sacral Base: R Posterior ILA: R Post./ Inf. STL: R Tight Motion Testing: Spring: - Sphinx: - L5: NSRRL Sacral Base L + R - ILA: L +/- R +/- Note: Seated flexion test may be + on L with this dysfunction (confirmatory) Left Right Neutral - Right Oblique Axis Findings: Name: R on ROA, RR on ROA, R forward torsion Lateralization: Right Landmarks: Sacral sulcus: L deep Sacral base: L anterior ILA: R Post/Inf. STL: R tight Motion Testing: Spring: - L5: SRRL Sacral Base: L + ILA: R +/- Midline

OMT Techniques Indirect Direct Physiologic response Doc takes segment in direction of somatic dysfunction/ease Ex: LonL => doc exaggerates left rotation of the sacrum on a left oblique axis Direct Doc takes segment in direction opposite of somatic dysfunction/into the barrier Ex: LonL => doc creates RonR Physiologic response Doc utlizes body (sacral) mechanics to create opposite rotation around same axis => make a neutral into non-neutral or visa versa Ex: LonL => doc helps create RonL

Neutral Sacral Rotation: L on LOA Supine, Indirect: Inherent/Resp Neutral Sacral Rotation: L on LOA Supine, Indirect: Inherent/Resp. force Patient supine and physician at side of patient Physician places hand under sacrum with fingers at sacral base and palm cupping sacral apex Apply anterior pressure to Right sacral base opposite oblique axis to induce anterior rotation Adjust flexion and extension for balanced ligamentous tension Follow respiratory cycle with exaggeration of motion and provide respiratory force at the point of balanced ligamentous tension Repeat until best motion palpated Respiratory force: Inhale: exaggerate backward torsion

Supine-Indirect Method-Respiratory Force (4522 Supine-Indirect Method-Respiratory Force (4522.11C): Treating L on LOA (rotated Left on a Left Oblique Axis) Example: L on LOA DO applies tension with fingers on sacral base to move right base further anterior Patient’s respiratory cycle is monitored to determine greatest sense of ease Encourage their diagnosis to balance ligamentous tension

Neutral Sacral Rotation: L on a L Oblique Axis (L on LOA) Sitting, Direct, articulatory, Pt. coop. Patient seated and physician behind patient Use thumb to monitor for motion at sacral base on side of diagnosed oblique axis Opposite hand grasps shoulder to guide patient into R sidebending toward opposite side of diagnosed oblique axis and L rotation (L5 NSRRL) Induces a R on ROA Instruct patient to “Arch your back” and then “Slump forward” Continue extension and flexion cycle of LS junction while adjusting sidebending and rotation until sacrum releases with motion at thumb “Cowboy Technique”

Left Non-Neutral Sacral Oblique Axis Somatic Dysfunction Name: R on LOA, RR on LOA, L Backward Torsion Landmarks: if calling findings on the L side in this example Sacral Sulcus: L Deep Sacral Base: L Anterior ILA: L Ant./Sup. STL: L Loose Motion Testing: Spring: + (It does not spring!) Sphinx: + (findings worsen with extension) L5: confirmatory FRLSL Sacral Base L - R +/- ILA: L + R +/- note: Seated flexion may be + on R with this dysfunction (confirmatory) L5: RLSL P+/- A+ Spring: + (It does not spring!) Sphinx: + (findings worsen with extension) KNOW what a + test means Remember, when you do moton testing at each sacral base and each ILA, that + motion indicates motion Where you have your axis = - motion (a lack of motion) Don’t screw this up. The only two that have a + spring and sphinx = bilateral sacral extension and a non-neutral (backwards torsion) KNOW THIS TOO Left Right Midline

Right Non-Neutral Sacral Oblique Axis Somatic Dysfunction Name: L on ROA, RL on ROA, R Backward Torsion Landmarks: if calling findings on R side in this example Sacral Sulcus: R Deep Sacral Base: R Anterior ILA: R Ant./ Sup. STL: R Loose Motion Testing: Spring: + Sphinx + L5: FRRSR Sacral Base L +/- R - ILA: L +/- R + note: seated flexion may be + on L with this dysfunction(confirmatory) L5: RRSR P+/- A+ Left Right Midline

Example: R on LOA Lumbar spine flexion > 90° with sidebending or twisting (RSL) Sacral findings: R base posterior, right ILA posterior and inferior, positive spring test Clinical example: bending forward, turning to the left, and trying to lift a laundry basket RL SL R on LOA A

Dx: Non-Neutral Sacral Rotation R on LOA Tx: Supine, Indirect, Inherent/Respiratory Forces Patient supine and physician at side of patient Physician places hand under sacrum with fingers at sacral base and palm cupping sacrum Apply anterior pressure to left ILA on side of oblique axis with the thenar/hypothenar eminence to induce anterior rotation of the ILA and posterior rotation of the opposite sacral base (in effect rotating the sacrum to the R) Recreate the dysfunction Adjust flexion and extension for balanced ligamentous tension Follow respiratory cycle at the point of balanced ligamentous tension Reassess

THANK YOU!!! Questions? Stuart F. Williams D.O. Chair and Associate Professor, OMM Edward Via College of Osteopathic Medicine, Carolinas Campus Spartanburg, SC 29303 swilliams@carolinas.vcom.edu