Sacral Diagnoses Stuart Williams D.O. Chairman & Associate Professor Osteopathic Manipulative Medicine Spring test + = non-neutral of sacrum base posterior bilateral sacral extension negative spring test = neutral and sacral base anterior Motion Testing: Spring: - (It springs!) Sphinx: - (improves with extension) Spring: + (It does not spring!) Sphinx: + (findings worsen with extension)

Spring Test Purpose: To be an indicator of whether you are dealing with a sacral Oblique Axis that is a Forward Torsion (Neutral) Backward Torsion (Non-Neutral). vs.

Spring Test 1. Find sacral base 2. Place heel of hand over Lumbosacral junction 3. Spring in an Anterior motion 4. Results: a. Positive test = If there is NO springing allowed = Non-neutral condition (AKA Backward torsion) b. Negative test = If there is springing allowed = Neutral condition.

Symmetry improves: negative test, neutral mechanics Worsening asymmetry: positive test, non-neutral mechanics Good test when having difficulty determining if you have neutral or non-neutral mechanics

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-

Direct Respiratory Force for Sacral Base Anterior Patient is prone with doctor at side of table Doctor places heel of hand on the ILAs, applying downward pressure Patient inhales, holding his/her breath in inhalation for as long as possible During inhalation apply a continuous anterior force on ILAs exaggerating sacral extension Resist sacral flexion during exhalation (hold in sacral extension) Repeat as necessary Recheck Nicholas p. 268

Sacral Base Posterior Name: Sacral Base Posterior, Bilateral Sacral EXTENSION Lateralization: Does NOT matter. Spring test: Positive Landmarks: Sacral Base: Bilaterally (B/L) Posterior Sacral Sulcus: B/L Shallow ILA: B/L Anterior STL: B/L Loose Motion: Sacral Base: B/L – ILA: B/L + Post - Post - Shallow Shallow Ant + Ant +

Bilateral Sacral Extension Patient prone, physician on dominate eye side. Place the thenar eminence of the treating hand over the sacral base . Abduct both legs until motion is felt by the palpating hand (~ 20), & then internally rotate the legs. Instruct pt to exhale fully & hold it. Exert a downward pressure over the sacral base while pt. inhales, resisting sacral extension. The pressure is maintained for 3 – 5 seconds while gapping the SI joints bilaterally. This may be accomplished by bending the patient’s knees 90  & gently internally rotating the patient’s abducted legs. Repeat above 2-3 times & recheck.

Direct Respiratory Force for Sacral Base Posterior Patient is prone, doctor at side of table Doctor places fingers on the sacral base, applying equal downward pressure to both sides Patient rests on his/her elbows – sphinx position Patient exhales completely and holds while doctor encourages anterior motion of the sacrum Repeat as necessary Recheck Nicholas P. 269

Vertical Axis Diagnosis: less common Name: Left Sacral Margin Posterior Lateralization: Matters NOT. Always call on Posterior side. For Left Sacral Margin Posterior: Landmarks: Sacral Base: L Posterior Sacral Sulcus: L Shallow ILA: L Posterior STL: L Tight Motion: Sacral Base: L – ILA: L – P – Shallow P - How could we treat this?

Findings for Unilateral Sacral Flexion (Sacral Shear) The sacral base on the side of the significantly inferior ILA will generally be anterior: FLEXED The ILA will be significantly inferior (& posterior!) {Sacrotuberous ligament will be pliable and under less tension than the contralateral side.} Anterior Posterior Markedly Inferior Right unilateral sacral flexion

Motion Testing for Unilateral Sacral Flexion (Sacral Shear) There will be no motion at the inferior ILA - it is locked down The base on the same side is likely to have adequate motion There is generally good motion at any of the other locations but the motion is not likely to “add up” or +/- +/- A - P/I (we can’t use our paper model for this one!) (No Axis.)

Supine, Direct, HVLA Unilateral Sacral Flexion (Sacral shear) and Upslipped Innominate Block inferior ILA with pt hand, wallet, towel, or wedge Grasp leg above ankle and abduct until SI joint is gapped Internally rotate leg to point of SI gapping Apply traction and then perform a swift tug (can use ME as in upslipped esp in geriatric pt.) right sacral shear Previously taught

Prone, Direct, Springing Sacral shear and upslipped innominate May stand or sit as shown, on same side as shear Find amount of abduction that gaps joint and internally rotate leg (see pdf and video) Thenar eminence on inferior ILA, other hand on top of it Pt breathes in; at height of inhalation - spring sacrum in an anterior/ superior direction left sacral shear This may be a muscle energy technique if you ask the patient to use their abductors to pull the leg on the affected side towards midline. Usual ME technique - Or have them hold to the point of air hunger with an inspiratory hold.

Unilateral Sacral Extension This is very rare, but I am adding it for completeness sake.

Unilateral Sacral Extensions Findings: Rare L Base P L sulcus shallow L ILA ant/markedly superior STL loose Spring: may be positive (no spring!) Motion: Sacral Base: L - R +/- ILA: L +/- R +/- S P- A +/- +/- A/S +/- P/I ASIS compression test + on L in this example.

Unilateral Sacral Extension Patient prone, physician on dysfunctional side. Place the thenar eminence of the treating hand over the sacral base of the dysfunctional side of the sacrum. Abduct ipsilateral leg until motion is felt by the palpating hand (~ 20), & then internally rotate the leg. Instruct pt to exhale fully & hold it. Exert a downward pressure over the sacral base while pt. inhales, resisting sacral extension. The pressure is maintained for 3 – 5 seconds while gapping the SI joint on the side of the dysfunction. This may be accomplished by bending the patient’s knee 90  & gently internally rotating the patient’s abducted leg. Repeat above 2-3 times & recheck.

Neutral Oblique Axis L on LOA R on ROA Tx: Laying Seated

Left Neutral Sacral Oblique Axis Somatic Dysfunction Name: L on LOA, RL on LOA, L Forward Torsion Seated Flexion: Positive on R (rec use for confirmation) Landmarks: if calling on L side as lateralized Sacral Sulcus: L Shallow Sacral Base: L Posterior ILA: L Post./ Inf. STL: L Tight Motion Testing: Spring: - (It springs!) Sphinx: - (improves with extension) L5: NSLRR Sacral Base L - R + ILA: L +/- R +/- L5: SLRR A + P+/- 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 +/- Left Right Midline

Right Neutral Sacral Oblique Axis Somatic Dysfunction P+/- A+ L5: SLRR Name: R on ROA, RR on ROA, R Forward Torsion Seated Flexion: Positive on L (confirmatory) Landmarks: 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 +/- Left Right Midline

Neutral Sacral Rotation on the Same Oblique Axis: Ex: L on LOA Prone, Physiologic response: Operator springing, ME, or Resp. force, or combine activating forces. Patient L lateral recumbent and physician facing patient Side of oblique axis toward table With knees bent, flex hips to greater than 90 degrees with knees off table Physician seated, support patient’s knees with thigh While monitoring lumbosacral junction (or sacral base), instruct patient to hug table (We LOVE neutrals!) until motion localized at lumbosacral junction Flex to > 90° Put him on his left side Tell him to hug the table Flex knee to 90 degrees  flattens lordosis Flexed. Rotate left. Sidebent left. (rotating L at lumbar = rotate right at sacrum) See if base comes posterior KEEP AXIS THE SAME Create a: R on LOA

Neutral Sacral Rotation: L on LOA (Rotated Left on a Left Oblique Axis) Prone, Physiologic response: Operator springing, ME, or Resp. force With forces localized at lumbosacral junction, grasp spinous process of L5 and pull away from table. You may also simply monitor the R sacral base to be sure it is moving posteriorly. Apply activating force to the patient’s feet toward floor to localize sidebending while monitoring sacral base opposite of axis LVMA springing ME Resp. force Can utilize a combination of the above forces. Repeat activating force until adequate motion felt at sacral base Recheck

Neutral Sacral Rotation: Rotated Left on a Left 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 Seated good for preggo women CHANGING THE AXIS ON THIS ONE!! L on LOA so instead of creating R on LOA  you create a R on ROA Sidbend R and rotate L = R on ROA

Non-neutral Oblique Axis L on ROA R on LOA Tx: Laying Seated

Left Non-Neutral Sacral Oblique Axis Somatic Dysfunction Name: R on LOA, RR on LOA, L Backward Torsion Lateralization: Right (use for confirmatory) Landmarks: calling Left lateralization 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 +/- L5: RLSL P+/- A+ Left Right Midline

Right Non-Neutral Sacral Oblique Axis Somatic Dysfunction Name: L on ROA, RL on ROA, R Backward Torsion Lateralization: Left (use for confirmatory) Landmarks: if patient lateralized Right 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 + L5: RRSR P+/- A+ Left Right Midline

Sacral Rotation on the Opposite Oblique Axis (Ex: R on LOA) Tx: Lateral Recumbent, Direct Physiologic Response, Respiratory force, Springing, ME Kimberly Manual 4525.11A, P 210-211 Patient lateral recumbent and physician facing patient Side of oblique axis toward table With knees bent, flex hips to less than 90 degrees with knees off table Draw shoulder on table forward so patient’s torso faces upward to induce rotation to lumbosacral junction Reverses rotation Physician seated, support patient’s knees with thigh Keep the axis Put on side of the axis Non-neutrals do not like the table Monitor at L5 or at the base Bend knees less than 90 degrees because he wants neutral mechanics SL RR L on LOA to fix R on LOA

Sacral Rotation on the Opposite Oblique Axis (Ex: R on LOA) Tx: Lateral Recumbent, Direct Physiologic Response, Respiratory force, Springing, ME Kimberly Manual 4525.11A, P 210-211 With patient’s knees balanced on thigh, apply activating force on feet toward floor Sidebending maintains axis Repeat activating force until adequate motion felt at sacral base LVMA springing ME Respiratory force Reassess SL RR Create L on LOA to fix R on LOA

Sacral Rotation of the Opposite Oblique Axis ( Ex: R on LOA) Tx: Sitting, Physiologic Response, ME Kimberly Manual: 4525.11B, P 211-212 Patient seated and physician behind patient Use thumb to monitor for motion at sacral base on opposite side of diagnosed oblique axis Opposite hand grasps shoulder on opposite side of oblique axis Guide patient into extension, rotation away from axis, and sidebending toward axis Instruct patient to gently try to bend to the side away from the axis while physician provides counterforce Patient then relaxes and physician moves to new barrier Reassess THIS IS DIFFERENT Pt is: SL RR Tell pt to straighten up This is the SAME as the previous slide just in a seated position Use NEUTRAL MECHANICS to fix the non-neutral

Pelvis Diagnosis

Lateralization Tests The lateralizing tests : standing flexion test (hamstrings, innominates, sacrum, spine) May be more specific to ilium motion on the sacrum: iliosacral motion 2. seated flexion test (innominates, sacrum, spine) Not influenced by hamstrings May be more specific to sacrum motion between ilia: sacroiliac motion 3. compression test (innominates & sacrum only) Not influenced by spine Often considered most specific

Standing Flexion Test Note the motion in the last 20 degrees of flexion Positive test - PSIS moves superiorly on side of dysfunction at the end range of motion…Iliosacral dysfunction… HOWEVER this could be a False positive Could be tight hamstrings on contralateral side

Seated Flexion Test Pt seated with legs at 90o Eliminates the influence of the lower extremities sacroiliac dysfunction Pt seated with legs at 90o Feet flat on floor or supported by ladderback stool Doc places thumbs on undersling of the PSIS. Pt bends forward at the waist SLOWLY reaching between knees

ASIS Compression Test Have the patient lie supine. The patient is then asked to raise his/her bottom up off the table and then set it back down again. * Doctor Stands with head and shoulders centered over the patient. Dominant eye centered over patients pelvic region** Contact the ASIS GENTLY Stabilize one ASIS while applying pressure at a 45 degree angle to the other ASIS Positive test - restricted movement of the SI joint > “brick like” limited motion Negative test - a sense of give or resilience => bounce or spring like motion, should sense on release as well as compression. *This is done to help them center their weight on the table. **(this is to help eliminate the effects of eye and hand dominance)

Landmarks-Call on side of lateralization. Supine: ASIS: S/I Pubic Symphysis: S/I & A/P Medial Malleoli: S/I Prone: PSIS: S/I (Ischial Tuberosity S/I) Write these down & record. Don’t try to “assume” a diagnosis while you are palpating. Trust your thumbs.

Innominate Diagnoses: Left Anterior Rotation Findings Left ASIS relatively inferior Left PSIS relatively superior S: pubic symphysis H: acetabulum X: inferior transverse axis

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 pubic shears and innominate flares). 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.” (Use ½ your strength) 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.

ANTERIOR INNOMINATE PRONE DIRECT MUSCLE ENERGY EX: Left Anterior Innominate. 1. Pt. prone and D.O. on side of dysfunction. 2. Extremity hangs freely off table. 3. Flex pt’s hip and knee. Grasp lower leg to do this. 4. Place pt’s foot flat against your thigh. 5. Other hand on posterior surface of sacrum. 6. Grasp knee & further flex hip & knee. 7. Lift pt’s knee & “squat” to raise foot superiorly. (rotates innominate posteriorly.) 8. “Push foot against my knee.” (Maintain isometric counterforce.) 9. After tissues relax, flex hip to rotate innominate posteriorly to new barrier. 10. Repeat until best motion. (usu. 3 times). Recheck.

Innominate Diagnoses: Left Posterior Rotation Findings Left ASIS relatively superior Left PSIS relatively inferior S: pubic symphysis H: acetabulum X: inferior transverse axis

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.

POSTERIOR INNOMINATE: PRONE- MUSCLE ENERGY 1. Pt. supine & D.O. on side opposite dysfunction. 2. Cephalad hand- hypothenar eminence on iliac crest & PSIS. 3. Caudad hand- grasp distal femur just above knee. 4. Extend hip to move innominate anteriorly to the restrictive barrier. 5. “Pull your knee down toward the table.” 6. Sense that force is localized at SI joint. 7. Extend extremity to new restrictive barrier. 8. Repeat until best motion. (usu. 3 times.) 9. Recheck.

Pubic Symphysis Somatic Dysfunctions Pubic Symphysis Superior/Inferior Shear Can be a SD by itself (rare) May often follow innominate SD (innominate ant/post rotation, up/down slipped innom). Can follow sacral shear Common in obstetrical patients due to relaxin Pubic Symphysis Anterior/Posterior Shear Relatively rare, usually caused by trauma Compression of the Pubic Symphysis Everything looks even, just tenderness, restricted motion

Innominate Inflare/Outflare Somatic Dysfunction Lateralized ASIS is closer to the umbilicus than the non-lateralized side i.e., with a left inflare, there is a shorter distance between the umbilicus and left ASIS than the right ASIS Outflare: Lateralized ASIS is further away from the umbilicus than the non-lateralized side i.e., with a left outflare, there is a longer distance between the umbilicus and left ASIS than the right ASIS Innominate inflare/outflare somatic dysfunction is not involved in inferior transverse axis mechanics It occurs about a vertical axis

INNOMINATE INFLARE TREATMENT 1. Pt. supine and D.O. on dysfunctional side. 2. Hip & knee partially flexed, foot on table close to buttocks. 3. Stabilize opposite ASIS. 4. Move knee laterally abducting thigh to innominate’s restrictive barrier. 5. “Move knee toward middle of table.” 6. Wait 3-5 seconds & abduct thigh to new restrictive barrier. 7. Repeat until best motion. (usually 3 times.) 8. Recheck.

INNOMINATE OUTFLARE TREATMENT 1. Pt. supine and D.O. on dysfunctional side. 2. Knee & hip partially flexed. 3. Grasp patella with one hand and hook fingers of the other hand over medial margin of involved PSIS. 4. Move knee medially adducting thigh to restrictive barrier. 5. “Move knee outward.” 6. Wait 3-5 seconds and adduct thigh to new restrictive barrier. 7. Repeat until best motion. ( ave. 3 times.) 8. Recheck.

Innominate Diagnoses: Left Inferior Pubic Shear Findings Left ASIS relatively inferior Left PSIS relatively superior S: pubic symphysis H: acetabulum X: inferior transverse axis Usually has an associated L anteriorly rotated innominate. Pubic shears can be only superior or inferior without innmominate rotations. This is usually from some type of trauma. Inferior Pubic Shear (physiologic) Tissue texture changes in the pubic region Superior surface of pubes is inferior (“step off sign”) Usually a positive flexion test on the side of the dysfunction Inferior glide of the pubic ramus is present Superior glide of the pubic ramus is restricted Tenderness to palpation over the pubic symphysis. May have symptoms of frequency and burning on urination even without infection May be seen with an innominate anterior.

TREATMENT: INFERIOR PUBIC SHEAR 1. Pt. supine and D.O. on side of dysfunction. 2. Flex lower extremity at knee and hip an abduct thigh to gap pubic symphysis. 3. Place knee against chest, cup cephalad hand against ASIS, grasp ischial tuberosity with other hand. (rotates innominate posteriorly to carry pubic symphysis superiorly.) 4. “Push knee toward end of table against my chest.” 5. Move innominate to new restrictive barrier. 6. Repeat until best motion. (approx. 3 times.) 7. Recheck.

Innominate Diagnoses: Left Superior Pubic Shear Findings Left ASIS relatively superior Left PSIS relatively inferior S: pubic symphysis H: acetabulum X: inferior transverse axis Usually associated with a posteriorly rotated innominate if physiologic. Superior Pubic Shear (physiologic) Tissue texture changes in the pubic region Superior surface of pubic ramus is superi9or (“step off sign”) on the dysfunctional side ASIS compression test is positive on the dysfunctional side Usually a positive flexion test on the side of the dysfunction Superior glide of the pubic ramus is present Inferior glide of the pubic ramus is restricted Tenderness to palpation over the pubic symphysis. May have symptoms of frequency and burning on urination even without infection. May be seen with an innominate posterior.

SUPERIOR PUBIC SHEAR 1. Pt. supine and D.O. on dysfunctional side between table & leg. 2. Stabilize opposite ASIS. 3. Have pt. move laterally until ischial tuberosity at edge of table. 4. Abduct knee to gap symphysis. 5. Extend thigh. (rotates innominate anteriorly and carries symphysis inferiorly.) 6. “ Lift knee toward ceiling.” Wait 3-5 seconds. 7. Extend thigh to new barrier. 8. Repeat until best motion. (av. 3 times.) 9. Recheck.

Innominate Diagnoses: Left Upslipped Innominate Findings Left ASIS relatively superior Left PSIS relatively superior S: pubic symphysis H: acetabulum X: inferior transverse axis Nonphysiologic. No axis! Symphysis and Ischial tuberosity could also be superior in more severe cases.

Supine, Direct, HVLA Sacral shear and upslipped innominate Block inferior ILA with pt hand, wallet, towel, or wedge Grasp leg above ankle and abduct until SI joint is gapped Internally rotate leg to point of SI gapping Apply traction and then perform a swift tug May also use ME (localize or tx) right sacral shear

Downslipped Innominate (Respiratory Cooperation) Dx - (+) StFT on affected side with all ASIS, PSIS, and pubic rami inferior aka, Inferior Pelvic Shear Tx – With patient lying on unaffected side and knees bent, apply an upward & lateral force on the ischial tuberosity & the ilium. Have patient take several deep breaths while you resist, & then advance cephalad as able & repeat. Recheck your findings. (Another treatment option is to have the patient hop on the affected leg several times and then recheck)

Lumbar Spine

Assess lordosis ROM Forward Bending Backward Bending (Seated) Trunk rotation (seated) Lumbar sidebending

RED REFLEX  use two/three fingers and drag down the back RED REFLEX  use two/three fingers and drag down the back. (TP, spine, TP) Red should go away quickly If the red stays longer than you should assume there may be acute somatic dysfunction Note: skin changes tenderness and prominence differences

Soft Tissue Techniques Prone- Direct, Kneading Lateral Recumbent- Direct, Kneading Prone- Direct Stretching Lateral Recumbent- Direct, Kneading and Stretching

Lumbar Paraspinal Muscles - Soft Tissue: Prone, Direct, Kneading

Soft Tissue: Lateral Recumbent-Direct-Kneading

Prone—Direct—Kneading and Stretching: 4913.11B

Lateral Recumbent—Direct– Kneading and Stretching: 4913.11C

Segmental Dx: L1 – L5 Sagittal Sidebend Rotate Should be: SL RR (then do not need to do saggital (should be normal/none) If the pt. is SL RL (or SR RR) then you should do the sagittal (flexion/extension) to see which non-neutral they are in.

Multiple Plane - Type I Mechanics Diagnosis Rotation palpation With the patient prone or seated, place your thumbs on a lumbar vertebra’s transverse processes located an inch lateral to the spinous process; Push anteriorly on the right TP to induce rotation left. Push anteriorly on the left TP to induce rotation right; Restricted rotation left = rotated RIGHT; restricted rotation right = rotated LEFT

Multiple Plane - Type I Mechanics Diagnosis Sidebending palpation Thumbs then slide medially to base of spinous process near the intervertebral space inferior to the lesioned body Apply motion testing in a medial direction Sidebending named for way it wants to go Concave side indicates direction of SB Sagittal plane Also check for non-neutral dysfunction (does it get better/worse in flexion/extension)

Practice Diagnose your partner for a Type 1 Mechanic dysfunction N SxRy Diagnose your partner for a Type II Mechanic dysfunction F/E RxSx

Treatment – Type I Mechanics Indirect technique Balanced ligamentous tension (BLT) Seated Supine Direct technique Muscle Energy (ME)

Common Diagnostic Findings Multiple Plane - Type I Mechanics Common Diagnostic Findings Example for N SL RR SB left presents approximation of L TP to segment below separation of R TP from segment below Left SB motion freedom, right SB motion restriction Rotation right presents right TP posterior left TP anterior right rotation freedom left rotation restriction

Multiple Plane - Type I Mechanics Indirect Treatment (BLT) **Sitting, indirect, pt coop, resp force. 4421.11D** Physician sits behind pt Physician contacts ipsilateral TP of segment below the rotated side (right TP of L4) Physician contacts contralateral TP on lesioned segment (left TP of L3) Pt is instructed to drop arm to induce further SB to float segment Pt is instructed to BB( “lean back”) to float the segment Pt instructed in respiratory force Recheck Example for L3 N SLRR

MULTIPLE PLANE-Type 1 Mechanics Indirect Treatment (BLT) MULTIPLE PLANE-Type 1 Mechanics Indirect Treatment (BLT) **Supine, indirect, pt cooperation, respiratory force 4422.11G** Pt is supine and the physician sits on the side of rotation (right) Physician reaches under pt and places pad of finger on the contralateral TP of dysfunctional segment – when applying anterior pressure will induce rotation into dx (right) Pt instructed to “arch back” or “flatten back” as needed to balance ligamentous tension in sagittal plane Apply anterior tension against contralateral TP (induce rotation) and apply traction to area gently creating SB (left) Pt instructed in respiratory force Repeat – avg 3 times Recheck DX: N SLRR

DX: N SLRR

Practice Indirect Techniques – Type I (neutral) Seated Supine

Multiple Plane - Type I Mechanics Direct Treatment (ME) **Sitting, direct, ME / HVLA 4421.11A or B ** N SLRR Salute rotated side R hand behind neck L hand on R elbow OR Put pt. in position as palpated place pt. hands to help you undo the setup Goal: pt. position opposite of diagnosis After Before

Multiple Plane - Type I Mechanics Direct Treatment (ME) **Sitting, direct, ME / HVLA 4421.11A or B ** Standing behind the seated patient, place your thenar eminence on the posterior TP(s) Reach across the upper chest with your other hand and arm to control the pts shoulders/trunk (under) Move trunk into the SB then rotation barriers until you feel movement at the restricted segments. Extend to localize in sagittal plane Ask pt to straighten the trunk/shoulders for 3-5 sec. against your equal resistance Allow FULL relaxation ( 3-5 sec) and then slowly move to new restrictive barrier as you push anterior into the posterior TP(s) Repeat 3-5 times Recheck

Multiple Plane - Type I Mechanics Direct Treatment (ME) Multiple Plane - Type I Mechanics Direct Treatment (ME) **Supine, direct, ME / HVLA 4421.11F ** Pt is supine and physician stands on pts side of rotation (right) Pt is instructed to flex knees and hips and place feet flat on table creating lumbar flexion Physician grasps the spinous process of dysfunctional segment and pulls segment towards him/her to induce rotation into restrictive barrier (left) Physician uses other hand to pull pts feet toward him/her creating SB into restrictive barrier (right) Pt is instructed to “ put feet back on table while physician offers isometric counterforce for 3-5 sec Allow full relaxation ( 3-5 second) then positions to new barrier Repeat 3-5 times Recheck DX: N SLRR

Multiple plane – Type II Mechanics Non-neutral Somatic Dysfunction Vertebral units above and below may exhibit type I (neutral) mechanics. More painful. often associated with sympathetic hyperactivity in organs innervated by T12-L2 area.

Multiple plane – Type II Mechanics Diagnosis Ex: F RLSL Flexion component: Spinous process approximates the segment above Spinous process separates from the segment below Flexion is present Extension is restricted Rotation component L transverse process relatively posterior R transverse process relatively anterior Spinous process shifted to the right L rotation is present R rotation is restricted

Multiple plane – Type II Mechanics Diagnosis Ex: F RLSL Sidebending component: Approximation of L transverse process to segment below. Separation of R transverse process from segment below. L sidebending is present.R sidebending is restricted. Tenderness to palpation over the supraspinous ligament or articular capsules. Usually more painful than neutral. Diagnosis: Check with extension and flexion Usually a non-neutral is found at the apex of a neutral curve or beginning/end of a neutral curve

Multiple Plane - Type II Mechanics Direct Treatment (ME) Multiple Plane - Type II Mechanics Direct Treatment (ME) **Sitting, direct, ME 4421.11B ** Standing behind the seated patient, place your thenar eminence on the posterior TP/ or contacts SP Reach across the upper chest with your other hand and arm to control the pts shoulders/trunk (over) Move trunk into the rotation/SB/ sagittal plane barriers until you feel movement at the restricted segments. Ask pt to straighten the trunk/shoulders for 3-5 sec. against your equal resistance Allow FULL relaxation ( 3-5 sec) and then slowly move to new restrictive barrier as you push anterior into the posterior TP(s) Repeat 3-5 times Recheck

Patient salutes rotated side Operator’s arm over patient’s shoulder

Thumb contacts SP (can also place heel of L hand over L TP).

NN (F) RLSL contact the left TP with the heel of left hand

Operator applies force to localize sidebending

Right hand grasps right proximal humerus and guides patient’s lumbar spine into R sidebending, R rotation, and FB/BB as needed to take all 3 planes to their restrictive barriers. Patient then turns or bends against D.O. while D.O. maintains isometric counterforce. Wait!! (3-5 seconds at least) Sidebend, rotate, BB/FB (tiny increments to new barrier.) Move to new barrier. Repeat 3x. Recheck. (HVLA directed ant/sup with heel of left hand at same time with one body movement.)

Multiple Plane - Type II Mechanics Indirect Treatment (BLT) Multiple Plane - Type II Mechanics Indirect Treatment (BLT) **Supine, indirect, pt cooperation, respiratory force 4422.11E ** Pt supine with his/her hips and knees flexed and feet flat on table, physician on opposite side of rotation Physician reaches under the pt and grasps SP of involved vertebra to induce rotation into SD to the point of BLT Physician instructs pt to move your shoulders and feet to side of rotation/side bending – into dx to the point of BLT Pt instructed to “arch back” or “flatten back” Pt instructed in respiration Repeat – avg 3 times Recheck

Steps for successful manipulation of the spine Diagnose accurately. Decide what treatment to use, indications, contraindications, conditions of the patient, direct or indirect method. Apply the principles which guide the method chosen (localize to the point of ease or localize at the restrictive barrier in all 3 planes.) Hold the patient securely, but lightly and comfortably. Sense the patient relaxed and the forces localized. Use the correct direction and dosage of activating force. Recheck to determine the change produced