Transcript Multiple Plane - Type I Mechanics

Sacral Diagnoses
Stuart Williams D.O.
Chairman & Associate Professor
Osteopathic Manipulative Medicine
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.
2.
3.
4.
Find sacral base
Place heel of hand over Lumbosacral junction
Spring in an Anterior motion
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.
4
Sacral Base Anterior
Name: Sacral Base Anterior, Bilateral Sacral Flexion
Lateralization: Does NOT matter.
Spring test: Negative
Landmarks:
Sacral Base:
Sacral Sulcus:
ILA:
STL:
Bilaterally (B/L) Anterior
B/L Deep
B/L Posterior
B/L Tight
Ant +
Deep
Ant+
Deep
Motion:
Sacral Base:
ILA:
B/L +
B/L –
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
Sacral Base Posterior
Name: Sacral Base Posterior, Bilateral Sacral
EXTENSION
Lateralization: Does NOT matter.
Spring test: Positive
Landmarks:
Sacral Base:
Sacral Sulcus:
ILA:
STL:
Post Shallow
Bilaterally (B/L) Posterior
B/L Shallow
B/L Anterior
B/L Loose
Motion:
Sacral Base:
ILA:
Post Shallow
Ant + Ant +
B/L –
B/L +
9
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
Vertical Axis Diagnosis: less common
Name: Left Sacral Margin Posterior
Lateralization: Matters NOT. Always call on
Posterior side.
For Left Sacral Margin Posterior:
P–
Shallow
Landmarks:
Sacral Base:
Sacral Sulcus:
ILA:
STL:
L Posterior
L Shallow
L Posterior
L Tight
P-
Motion:
Sacral Base:
ILA:
L–
L–
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
Anterior
• The ILA will be significantly inferior (&
posterior!)
• {Sacrotuberous ligament will be
pliable and under less tension than
the contralateral side.}
Right unilateral sacral flexion
Posterior
Markedly
Inferior
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
right sacral shear
• 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.)
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.
20
Unilateral Sacral Extensions
• Findings:
– Rare
S
– L Base P
– L sulcus shallow
– L ILA ant/markedly superior
– STL loose
– Spring: may be positive (no spring!)
– Motion:
– Sacral Base: L – ILA:
L +/-
R +/R +/-
A+/-
P-
+/-
A/S
+/-
P/I
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
23
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)
A+
Landmarks: if calling on L side as lateralized
Sacral Sulcus:
Sacral Base:
ILA:
STL:
L Shallow
L Posterior
L Post./ Inf.
L Tight
P+/-
Motion Testing:
Spring:
Sphinx:
L5:
Sacral Base
ILA:
- (It springs!)
- (improves with extension)
NSLRR
LR+
L +/R +/-
Left
Right
Midline
Right Neutral Sacral Oblique Axis
Somatic Dysfunction
Name: R on ROA, RR on ROA,
R Forward Torsion
Seated Flexion: Positive on L (confirmatory)
A+
Landmarks:
Sacral Sulcus:
Sacral Base:
ILA:
STL:
R Shallow
R Posterior
R Post./ Inf.
R Tight
P+/-
Motion Testing:
Spring:
Sphinx:
L5:
Sacral Base
ILA:
NSRRL
L+
L +/-
RR +/-
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°
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
Non-neutral Oblique Axis
• L on ROA
• R on LOA
• Tx:
– Laying
– Seated
29
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:
Sacral Base:
ILA:
STL:
P+/-
L Deep
L Anterior
L Ant./Sup.
L Loose
A+
Motion Testing:
Spring: + (It does not spring!)
Sphinx: + (findings worsen with extension)
L5: confirmatory
FRLSL
Sacral Base
LR +/ILA:
L + R +/-
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:
Sacral Base:
ILA:
STL:
P+/-
R Deep
R Anterior
R Ant./ Sup.
R Loose
Motion Testing:
Spring: +
Sphinx +
L5:
Sacral Base
ILA:
A+
FRRSR
L +/- R L +/- R +
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
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
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
Pelvis Diagnosis
Lateralization Tests
The lateralizing tests :
1.
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
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.
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
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
8. “Push foot against my knee.” (Maintain isometric counterforce.)
9. After tissues relax, flex hip to rotate innominate posteriorly to new
10. Repeat until best motion. (usu. 3 times). Recheck.
posteriorly.)
barrier.
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
Inflare:
 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 nonlateralized 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
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.
medial margin of
Innominate Diagnoses:
Left Inferior Pubic Shear
 Findings


Left ASIS relatively
inferior
Left PSIS relatively
superior
S: pubic symphysis
H: acetabulum
X: inferior transverse axis
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
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
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
REFLEX  use two/three fingers and drag down the
back. (TP, spine, TP)
 RED



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
 4913.11A
Soft Tissue: Lateral Recumbent-DirectKneading
 4913.11D
Prone—Direct—Kneading and Stretching:
4913.11B
Lateral Recumbent—Direct– Kneading and
Stretching: 4913.11C
 Segmental




L1 – L5
Sagittal
Sidebend
Rotate
Dx:
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
1.
Thumbs then slide medially to base of spinous
process near the intervertebral space inferior to the
lesioned body
2.
Apply motion testing in a medial direction
3.
Sidebending named for way it wants to go
4.
Concave side indicates direction of SB
Sagittal plane
Also check for non-neutral dysfunction
(does it get better/worse in flexion/extension)
Practice
 Diagnose

N SxRy
 Diagnose

your partner for a Type 1 Mechanic dysfunction
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)
• Seated
• Supine
Multiple Plane - Type I
Mechanics
SB left presents
Common Diagnostic Findings
Example for N SL RR
• 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**
1. Physician sits behind pt
2. Physician contacts ipsilateral TP of
segment below the rotated side (right TP
of L4)
3. Physician contacts contralateral TP on
lesioned segment (left TP of L3)
4. Pt is instructed to drop arm to induce
further SB to float segment
5. Pt is instructed to BB( “lean back”) to
float the segment
6. Pt instructed in respiratory force
7. Recheck
Example for L3 N SLRR
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)
N SLRR
**Sitting, direct, ME / HVLA 4421.11A or B **
•
•
•
Salute rotated side
R hand behind neck
L hand on R elbow
OR
•
•
Before
Put pt. in position as
palpated
place pt. hands to help
you undo the setup
Goal: pt. position opposite of diagnosis
After
Multiple Plane - Type I Mechanics
Direct Treatment (ME)
**Sitting, direct, ME / HVLA 4421.11A or B **
1. Standing behind the seated patient, place your
thenar eminence on the posterior TP(s)
2. Reach across the upper chest with your other
hand and arm to control the pts shoulders/trunk
(under)
3. Move trunk into the SB then rotation barriers
until you feel movement at the restricted
segments. Extend to localize in sagittal plane
4. Ask pt to straighten the trunk/shoulders for 3-5
sec. against your equal resistance
5. Allow FULL relaxation ( 3-5 sec) and then slowly
move to new restrictive barrier as you push
anterior into the posterior TP(s)
6. Repeat 3-5 times
Multiple Plane - Type I Mechanics
Direct Treatment (ME)
**Supine, direct, ME / HVLA 4421.11F **
1.
2.
3.
4.
5.
6.
7.
8.
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)
**Sitting, direct, ME 4421.11B **
1.
2.
3.
4.
5.
6.
7.
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)
**Supine, indirect, pt cooperation, respiratory force 4422.11E **
1.
2.
3.
4.
5.
6.
7.
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
1.
2.
3.
4.
5.
6.
7.
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