The Dirty Half Dozen An osteopathic approach to mechanical

back pain

Heather Ferrill DO, MS SOFMOO 2018

Paris

The “Dirty Half-Dozen” &

Considering What Happens When Tensegrity Met Janda

An Osteopathic Approach to Mechanical Low Back Pain

Michael L. Kuchera, DO, FAAO, FNAOME Secretary-General, FIMM

Board of Governors, American Academy of Osteopathy Professor, Department of OMM

Proposed Minnesota College of Osteopathic Medicine

ATStill21@Hotmail.com

Discuss 6 significant somatic dysfunction causes of chronic, recurrent mechanical low back pain and outcome of treatment using osteopathic manipulative treatment (OMT) Discuss impact of certain subsets and

patterns of muscular somatic dysfunction in perpetuating lumbopelvic pain Impact on form & force closure Impact when tensegrity meets neurology

Recommended order (empiric & pragmatic)

OVERVIEW

The “Dirty Half-Dozen” Somatic Dysfunctions

“Half-Dozen” (6)

“Dirty” for their role in chronic, recurrent low back pain

EBM: “Dirty Half-Dozen” Reasons for Recalcitrant LBP

Non-Physiologic SD Pubic Shear Innominate Shear Sacral Shear

Other Somatic Dysfunction Muscle Imbalance / especially

Ilio-Psoas Syndrome “Non-Neutral” Lumbopelvic SD Short-Leg Syndrome

Greenman: 183 consecutive disabling LBP patients (ave=31 mon); 50%: 3-6 “Dirty ½ Dozen” diagnosis; OMT= return to work / ADLs for 75%

Greenman PE. Sacroiliac dysfunction in the failed low back pain syndrome. 1st Interdisciplinary World Congress on LBP & Its Relation to the Sacroiliac Joint, San Diego,

1992, pp 329-352. Article in Phys Med Rehab Clin North Am 1996; 7:773-785.

Greenman PE. Principles of Manual Medicine. Lippincott Williams & Wilkins, 2003. 591-592

Identified Somatic Dysfunctions

76%

15%

49%

63%

90%

85% Non-Neutral (Type II) Lumbar SD

Iliopsoas & Other Muscle Imbalance

“Short Leg” Syndrome & Postural Ms Imbalance (Unlevel Sacral Base)

Sacral Nutation Failure including Non-Neutral SD (Backward Sacral Torsion)

SI Shears (Sacral Shear SD) (Innominate Shear SD)

Pubic Shear SD

“Dirty Half-Dozen” Somatic Dysfunctions (SD) in Persistent Low Back Pain (PLBP) - Greenman

ASIS Compression Test A Lateralization Test

Objective During This Pelvic Lateralization Test

Glide along SI Joint Avoid Rolling Pelvis

Positive on Side of Restriction

Posterior Sacroiliac Lig

Block to prevent rolling

Posteromedial

Pubic Shear or Compression

Somatic Dysfunction

superior-inferior “stairstep”

Pubic Shear (inferior or superior) - lateralized side

“Pubic Compression”: Pain; no step

Pubic symphysis somatic dysfunction • 75% of patients in the DHD

study had pubic symphysis unleveling

• Somatic dysfunction causes distortion of the pelvic brim • Increases the force load

across the SIJ’s • Most commonly right

inferior (32%), left superior (25%) • Hypertonic adductors • Weak lower abdominals

Can confound the diagnosis of innominates and sacrum

treat the pubic symphysis first

Innominate Shear Somatic Dysfunction

Superior Innominate Shear on the left

Iliac crest

ASIS

Ischial Tub.

Posterior: PSIS also asymmetric

ASIS Compression + on Left

Sacral Shear Somatic Dysfunction

Sacral Somatic Dysfunctions

48.8% of DHD study patients had a restriction to anterior nutation of the sacrum

• Backward torsion • L on R = 17.5% • R on L = 15.8%

• Bilaterally extended= 15.3%

Lumbar Dysfunctions

• 84% of DHD patients had Type II lumbar dysfunctions • Most had multiple dysfunctions especially at L4 & L5

Short-leg, pelvic-tilt • 63% of DHD study

patient had this present • Short leg on one side

creates a constellation of structural dysfunctions • LE somatic dysfunction • Innominate rotations • Pelvic unleveling • Spinal asymmetry

• Coronal plane (sidebending)

• Chronic Type I dysfunctions

• Muscular imbalance • Shoulder asymmetry

Postural Imbalance &

Lower Crossed Syndrome

Contributions of Janda-Lewit School to Understanding Muscle Imbalance &

Travell Trigger Points

Neurological Impact Tonic-Phasic Muscles

Tonic = Postural Muscles ◦ Often the long restrictors (cross

2 or more joints) ◦ Become hypertonic when

stressed ◦ May develop myofascial

triggerpoints (MTrPs) Phasic = Postural Antagonists ◦ May be stressed or may be

neurological reaction to stress on tonic muscle ◦ When stressed, act weak

(“pseudoparetic”) ◦ May also develop MTrPs

• Lower Crossed Syndrome of Tonic-Phasic Imbalanced Muscles with Pattern

• Postural muscles tend to be tonic and their antagonists neurologically are phasic

• Both must consider postural decompensation as underlying precipitating & perpetuating factors

Trigger Points

• Classic referral pain patterns • Cause of altered muscular

firing and core instability

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Form & Force Closure

Impact of Gluteii Especially

Self-Bracing Mechanism

Model that allows for efficient locomotion and weight transfer, structural integrity as well as mobility

Attained by form + force closure

Form closure via structural anatomy of wedge shaped sacrum Force closure requires horizontal, compressive force and friction to

withstand vertical load

Vleeming, 1995

Form Closure

– Flat surfaces of the SIJ are susceptible to shear forces – The wedge shape protects the SIJ from shearing forces in two ways:

• In the AP plane: being wider anteriorly than posteriorly allows the sacrum to nutate to protect

• In the vertical plane: wider superiorly than inferiorly protects against gravity and forces from below

Major impact of hyper or hypolordosis

Force Closure

Key Force Closure Muscles Gluteus medius & minimus are

phasic muscles – When stressed they can’t help in force closure

Positive Trendelenberg

Treatment Order Considerations

TREATMENT SEQUENCE PLENARY SESSION

1. Pubic symphysis dysfunctions 2. Innominate shears 3. Sacral dysfunctions 4. Lumbar Type II’s 5. Address any trigger points Correct

muscle imbalance with home exercise and retraining program

6. Correct short leg if present

The Dirty Half Dozen An osteopathic approach to mechanical

back pain

Heather Ferrill DO, MS SOFMOO 2018

Paris

Lecture objectives • List and describe the 6 primary areas of somatic

dysfunction associated with persistent low back pain • Describe the most common patterns associated with each

of the Dirty Half Dozen (DHD) and their relative prevalence in persistent LBP patients

• Describe form and force closure of the pelvis – The muscle-tendon-fascia mechanism

• Describe how somatic dysfunction of the above areas contribute to instability and pain

• Describe the evaluation and diagnostic criteria for each of the above areas of somatic dysfunction

• Describe the suggested treatment sequence when working with patients with persistent low back pain

• Describe the set up and treatment for each of the above areas

Goals

• Persistent mechanical LBP and pelvic pain – Commonly found musculoskeletal dysfunctions – Form and force closure model of pelvic stability – Arthokinematic inhibition of core musculature &

destabilization

LBP

• 80% of low back pain is idiopathic – WHY?

• LOOK UP STATS WORLDWIDE AND FRANCE – Out of work – Mechanical v surgical

The Dirty Half Dozen Study • Looking for mechanical reasons and interventions

for persistent LBP • 183 patients with “Failed low back syndrome” (79

male, 104 female) • Avg. age 40.8 • Disabled avg. 30.7 mo • Found 6 somatic dysfunction present in most patients

• 2.7% had none of the DHD • 55% had three or more of the DHD • 75% of the patients returned to full employment and ADL’s

following treatment plan and home exercise/stretch regimen despite and average of 2.5 years disability!!!

The Dirty Half Dozen

1. Non-neutral dysfunction within the lumbar spine

2. Pubic symphysis dysfunctions 3. Posterior extensions or torsions of the

sacrum 4. Innominate shears 5. Short-leg, pelvic-tilt syndrome 6. Muscle imbalance of the trunk and LE

Dysfunctions of the Pelvis

• Pubic symphysis dysfunction • Innominate dysfunctions

Pubic symphysis

• Pubic rami must be able to move superiorly and inferiorly during the gait cycle

• Aids in distribution of forces from the femur into the pelvis and across the SIJ’s

Pubic symphysis somatic dysfunction • 75% of patients in the DHD

study had pubic symphysis unleveling

• Somatic dysfunction causes distortion of the pelvic brim • Increases the force load

across the SIJ’s • Most commonly right

inferior (32%), left superior (25%) • Hypertonic adductors • Weak lower abdominals

Can confound the diagnosis of innominates and sacrum

treat the pubic symphysis first

Short-leg, pelvic-tilt • 63% of DHD study patient had this present

• Short leg on one side creates a constellation of structural dysfunctions • LE somatic dysfunction • Innominate rotations • Pelvic unleveling • Spinal asymmetry

• Coronal plane (sidebending)

• Chronic Type I dysfunctions

• Muscular imbalance • Shoulder asymmetry

Sacral dysfunctions

48.8% of DHD study patients had a restriction to anterior nutation of the sacrum

• Backward torsion • L on R = 17.5% • R on L = 15.8%

• Bilaterally extended= 15.3%

Self-Bracing Mechanism

Model that allows for efficient locomotion and weight transfer, structural integrity as well as mobility

Attained by form + force closure

Form closure via structural anatomy of wedge shaped sacrum Force closure requires horizontal, compressive force and friction to

withstand vertical load

Vleeming, 1995

Form closure • Flat surfaces of the SIJ are susceptible to shear forces

• The wedge shape protects the SIJ from shearing forces in two ways:

• In the AP plane: being wider anteriorly than posteriorly allows the sacrum to nutate to protect

• In the vertical plane: wider superiorly than inferiorly protects against gravity and forces from below

• Begins in the LE through force coupling • Heel strike: peroneus longus and biceps femoris into the sacrotuberous

ligament and across the ipsilateral SIJ • Midstance: downward force of Biceps femoris contraction countered by

upward contraction of ipsilateral gluteus maximus and contralateral latissimus dorsi through thoracolumbar fascia

Creates a muscle-tendon-fascial sling that is temporally precise: any delay in firing of these mm decreases the stability of the entire mechanism

Force closure

Sacroiliac joint dysfunctions

• Multifaceted problem – Altered SIJ function results in loss of form closure

• Counternutation dysfunctions are particularly painful and problematic due to loss of stability provided by sacral nutation

– And also leads to loss of force closure • Leads to arthrokinematic inhibition of Gluteus

Maximus diminishing force closure and destabilizing the muscle-tendon-fascia sling

Lumbar dysfunctions • 84% of DHD patients had Type II dysfunctions of the lumbar

spine • ERS = 34.9% • FRS = 83.6%

• Most had multiple dysfunctions and were clustered at L4 & L5

• Type II dysfunctions inhibit transversospinal function • These work synergistically with transversus abdominus and internal

obliques, thoracolumbar fascia, iliopsoas and quadratus lumborum • Inhibition of transversospinal mm leads to decoupling of entire core

mechanism

Loss of core control

Muscle imbalance

• Greater than 95 % of population had significant muscle imbalance between trunk and lower extremities.

• Primarily tight hip flexors, tight piriformis, tight adductors, weak abdominals, weak gluteus maximus and medius.

• Poor proprioceptive balance and trunk rotator control.

Core control is key • Abdominal muscles

notoriously weak – Transversus abdominus

essential for core control – TA fires first with all upper

and lower extremity motion

– In patients with persistent or recurrent LBP TA shows delayed firing

– Leads to decreased core control and increased instability

Trigger points

• Classic referral pain patterns • Cause of altered muscular

firing and core instability

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Trigger points Muscle Referral pattern Patient complaint Rectus abdominus Bilateral symptoms across upper

or lower back, precordial pain/fullness, nausea/vomiting

Urinary urgency/frequency, bladder pain, perineum pain, buttock pain, iliosacral back pain

Internal abdominal oblique Groin, genital pain, lower quadrant abdominal pain

Pelvic pain

Transversus abdominus Groin, genital pain, lower quadrant abdominal pain

Low belly or pelvic pain

Pyramidalis Pain bladder, urethra, pubic bone, SIJ, buttock, hip

SIJ, buttock, hip pain especially with sitting and standing

Hip adductors: adductor longus, adductor brevis, adductor magnus, gracilis

Deep pelvic pain, groin, medial thigh, knee, & shin pain

Tenderness in any of the referred pain zones, pelvic pain

Bulbocavernosus, ischiocavernosus, transversus perineum

Perineal pain, urogenital structures

Dyspareunia

Obturator internus Anal, coccyx, vulvar, urethral, vaginal, or posterior thigh pain

Generalized pelvic pain, with or without burning or aching

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Summary

• Trigger points – Cause referral pain patterns – Cause muscular firing patterns contributing to

core instability

• Muscle imbalance – Core weakness, alternating hypertonicity in other

areas to compensate

Treatment sequence

Pubic symphysis dysfunctions Innominate shears Sacral dysfunctions Lumbar Type II’s Correct short leg if present Address any trigger points Correct muscle imbalance with home exercise

and retraining program

References & additional resources • Greenman, PE. Syndromes of the lumbar spine, pelvis, and sacrum. Phys Med Rehabil Clin N Am 1996;7(4):773-

785. • Pastore EA, Katzman WB. Recognizing Myofascial Pelvic Pain in the Female Patient with Chronic Pelvic Pain. Journal

of obstetric, gynecologic, and neonatal nursing : JOGNN / NAACOG. 2012;41(5):680-691. doi:10.1111/j.1552-6909.2012.01404.x.

• Vleeming, A., et al. The functional coupling of the deep abdominal and paraspinal muscles: the effects of simulated paraspinal muscle contraction on force transfer to the middle and posterior layer of the thoracolumbar fascia. Journal of anatomy 225.4 (2014): 447-462.

• Hodges, Paul W., and Carolyn A. Richardson. "Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds." Archives of physical medicine and rehabilitation 80.9 (1999): 1005-1012.

• Hungerford, Barbara, Wendy Gilleard, and Paul Hodges. "Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain." Spine 28.14 (2003): 1593-1600.

• van Dieën, Jaap H., Jacek Cholewicki, and Andrea Radebold. "Trunk muscle recruitment patterns in patients with low back pain enhance the stability of the lumbar spine." Spine 28.8 (2003): 834-841.

• Hodges, Paul W., et al. "Experimental muscle pain changes feedforward postural responses of the trunk muscles." Experimental brain research 151.2 (2003): 262-271.

• Ferreira, Paulo H., Manuela L. Ferreira, and Paul W. Hodges. "Changes in recruitment of the abdominal muscles in people with low back pain: ultrasound measurement of muscle activity." Spine 29.22 (2004): 2560-2566.

• ScienceDirect (Online service). Movement, stability & lumbopelvic pain: integration of research and therapy. Eds. Andry Vleeming, Vert Mooney, and Rob Stoeckart. Edinburgh: Churchill Livingstone Elsevier, 2007.

• Travell, Janet G., and David G. Simons. Myofascial pain and dysfunction: the trigger point manual. Vol. 2. Lippincott Williams & Wilkins, 1983.

• Anderson, Rodney U., et al. "Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men." The Journal of urology 174.1 (2005): 155-160.

• Anderson, Rodney U., et al. "Painful myofascial trigger points and pain sites in men with chronic prostatitis/chronic pelvic pain syndrome." The Journal of urology 182.6 (2009): 2753-2758.

• Weiss, Jerome M. "Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome." The Journal of urology 166.6 (2001): 2226-2231.