Transcript Sacral Base L + R

OMM FOR THE PREGNANT PATIENT
STUART WILLIAMS DO, CHAIRMAN AND ASSOCIATE PROFESSOR, OMM
STUART WILLIAMS D.O.
C HA IR M A N & A S S O C IAT E PRO FE S S O R
O ST E O PAT HIC M A N IPU LAT IV E M E D IC IN E
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)
– IVC pressure increases
• LBP
– Usually pelvic, innominate, and sacral pain
– Lumbar discomfort as well
Differential for LE Swelling
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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
Differential Dx for LBP in Pregnancy
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Spinal facet
Leg-length inequality
Overweight
Trauma
Scoliosis
Somatic dysfunction
Spondylolisthesis
Congenital
Multiple gestations
Discogenic
Ligamentous laxity
Differential Dx cont.
• Viscerogenic
– Urinary tract
– Bowel function
– Endometriosis
– Pelvic Infection
– Labor
Vascular
compression of gr v.
venous plexopathy
thrombosis
placental location
Changes in Pregnancy
• Center of Gravity
– Affects both:
• Posture – lordosis tips sacrum forward
• Gait
LBP
• Both Joint motion restrictions and hypermobility!
• Pressure from expanding uterus
– Decreases venous and lymphatic drainage esp from
dependent areas (LE)
Edema
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
Physical Examination
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Observation
Palpation
ROM (screening)
Muscle Imbalances
DTRs
Posture
Degree of lumbar lordosis
Contraindications to OMT in Pregnancy
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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.
Edema
• Goal: efficient and effective venous and
lymphatic drainage
• Areas of Restriction to flow to address:
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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
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.
Plantar Fascia
Interosseous Membrane
Interosseous Membrane
21
Fibular Head and Interosseous Membrane
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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
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Fibular Head and Interosseous Membrane
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Treatment.
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6.
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.
Popliteal Fascia
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.
Direct MFR: Popliteal Fascia
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Procedure:
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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.
Pelvic Diaphragm
Ischiorectal Fossa Release and Dome Pelvic Diaphragm
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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
Pages 56-58 in the Kimberly Manuel
Ischiorectal Fossa Release and Dome Pelvic Diaphragm
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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
Pelvic Region Ischiorectal Fossa Release, Supine
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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.
PUBIC DECOMPRESSIONMUSCLE 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)
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.
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.
Soft Tissue
LUMBAR REGION-MUSCLE ENERGY
LUMBAR NEUTRAL
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SEATED-DIRECT METHOD – MUSCLE ENERGY
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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
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
Sacrum
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-
Vertical Axis Diagnosis: less common
Name: Left Sacral Margin Posterior
Lateralization: Matters NOT. Always call on
Posterior side.
Shallow
P–
A+
For Left Sacral Margin Posterior:
Landmarks: data recorded on lateralized side
Sacral Base:
Sacral Sulcus:
ILA:
STL:
L Posterior
L Shallow
L Posterior
L Tight
P-
Motion:
Sacral Base:
ILA:
L–
L–
R+
R+
How could we treat this?
A+
Deep
*Also used for lumbar SD, “OB Roll”
Sacral Diagnosis
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Named for upper pole of sacrum
Forward Torsion
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Neutral
Rotation in same direction
Left rotation on left oblique axis
Right rotation on a right oblique axis
Backward Torsion
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Non-neutral
Rotation in opposite direction
Right rotation on left oblique axis
Left rotation on a right oblique axis
L
R
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:
Sacral Base:
ILA:
STL:
L Shallow
L Posterior
L Post./ Inf.
L Tight
Motion Testing:
Spring:
Sphinx:
L5:
Sacral Base
ILA:
A+
P-
P+/- (It springs easily!)
- (improves with extension)
NSLRR
LR+
L +/R +/-
note: Seated Flexion test may be + on R with this dysfunction (confirmatory)
+/-A
Left
Right
Midline
Right Neutral Sacral Oblique Axis
Somatic Dysfunction
Name: R on ROA, RR on ROA,
R Forward Torsion
Landmarks: if recording findings on R side
Sacral Sulcus:
Sacral Base:
ILA:
STL:
A+
R Shallow
R Posterior
R Post./ Inf.
R Tight
Motion Testing:
Spring:
Sphinx:
L5:
Sacral Base
ILA:
NSRRL
L+
L +/-
P+/-
RR +/-
Note: Seated flexion test may be + on L with this dysfunction (confirmatory)
Left
Midline
Right
OMT Techniques
• Indirect
– 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. force
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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
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
Neutral Sacral Rotation: L on a L Oblique Axis (L on LOA)
Sitting, Direct, articulatory, Pt. coop.
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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
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:
Sacral Base:
ILA:
STL:
L Deep
L Anterior
L Ant./Sup.
L Loose
P+/-
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)
A+
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:
Sacral Base:
ILA:
STL:
R Deep
R Anterior
R Ant./ Sup.
R Loose
P+/-
Motion Testing:
Spring: +
Sphinx +
L5:
Sacral Base
ILA:
A+
FRRSR
L +/- R L +/- R +
note: seated flexion may be + on L with this dysfunction(confirmatory)
Left
Right
Midline
Example: R on LOA
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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
A
Dx: Non-Neutral Sacral Rotation R on LOA
Tx: Supine, Indirect, Inherent/Respiratory Forces
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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)
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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
[email protected]