Aubrey Taow, DO 2016 FOMA Convention February 19, 2016valuable tools in diagnosing and treating low...

Aubrey Taow, DO

2016 FOMA Convention

February 19, 2016

Osteopathic structural exam and osteopathic manipulative treatment are

valuable tools in diagnosing and treating low back pain

Remember the guiding principles for treating soft tissue injury

1. Identify and eliminate possible causes of pain (e.g. poor posture, abnormal

biomechanics)

2. Reduce pain and inflammation

3. Restore full pain-free range of motion

4. Achieve optimal flexibility and strength

5. Maintain fitness

1. Visual inspection of back and

posture

From behind and from the side

2. Active movements

Flexion

Extension

Lateral flexion

Single-leg extension

3. Palpation of spine and paraspinal

muscles

Spinous processes

Transverse processes

Apophyseal joints

Sacroiliac joints

Iliolumbar ligament

Paraspinal muscles

Quadratus lumborum

Gluteal muscles

4. Neurologic assessment of L4, L5,

and S1 nerve roots

5. Special tests

Unilateral straight leg raise test (Lasegue

test)

Crossed straight leg raise test (Well

straight leg raise test)

Slump test

Femoral nerve stretch test

Sacroiliac joint tests

Patrick or FABER test

Gaenslen’s test

Single leg extension

Centralization test

Hip Flexion (Iliopsoas)

L1, L2, L3, L4 (Femoral Nerve)

Knee Extension (Quadriceps)

L2, L3, L4 (Femoral N)

Knee Flexion (Hamstrings)

(L4), L5, S1, S2, (S3) (Tibial N)

Ankle Dorsiflexion (Tibialis Anterior)

L4, L5 (Deep Fibular N)

Great Toe Extension (Extensor Hallucis Longus)

L5, S1 (Deep Fibular N)

Ankle Plantar Flexion (Gastrocnemius)

S1, S2 (Tibial N)

Assessment for sciatic nerve compression (80% sensitive)

How to perform:

With the patient supine, lift leg up while keeping knee extended

When the patient experiences pain/tightness, slowly lower the leg until the pain

resolves. Then dorsiflex the ankle and have the patient flex his neck.

Positive test: pain at 30-60° that radiates down the leg being raised

Indicates sciatic nerve root irritation

Pain after 70 ° may be indicative of muscle stretching, sacroiliac pain or

lumbar facet joint pain

How to perform:

Same as SLR

Positive test: pain radiates down the side opposite of the leg being

raised

Indicates herniated intervertebral disc that is irritating the nerve root (as

opposed to sciatic nerve irritation)

Assessment for movement

restriction or impingement of

the dura and spinal cord

How to perform:

1.Patient seated at the edge of

the table with legs hanging off

the table and hands behind his

back. Instruct patient to

slump forward into thoracic

and lumbar flexion, while

keeping neck and head in

neutral position and sacrum

vertical.

http://lumbar-spine-special-test.blogspot.com/

How to perform (continued)

2. If there are no reproduction of

neurologic symptoms, then the

physician adds the folowing

modifications:

a.) Instruct patient to put chin on

chest and apply overpressure.

b.) While maintaining overpressure,

patient actively extends the knee.

Positive test: Reproduction of

pain or neurologic symptoms

Indicates impingement of dural

lining, spinal cord, or nerve

roots

http://lumbar-spine-special-

test.blogspot.com/

Tests for nerve root impingement at L2,

L3, L4

How to perform:

Patient is lying prone with a pillow under

the abdomen. The examiner stands at the

patient’s side.

The examiner stabilizes the patient’s far

hip with the heel of his cephalad hand

over the PSIS. He then passively extends

the far hip, while holding the knee flexed

at 90°

Positive test: Pain in anterior and lateral

thigh

Assesses for dysfunction of anterior SI ligament

How to perform:

Patient lies supine with her forearms under her lower back to support the

lumbar spine and a pillow under her knees.

With arms crossed and elbows straight, the examiner places the heels of his

hands on the patient’s ASIS and applies a slow steady posterior force by leaning

down toward the patient

Positive test: Unilateral pain at SI joint or in gluteal/leg region

http://si-bone.com/providers/sacroiliac-joint-diagnosis/si-joint-

provocative-tests/

Assesses for dysfunction of sacrospinous ligament

How to perform:

Patient lies supine with hip being tested flexed to 90 degrees and knee fully

flexed. Examiner stands on the same side as the flexed leg.

While stabilizing the opposite ASIS with heel of cephalad hand, the examiner

uses his upper body to apply a steady pressure through the axis of the femur

Positive test: Pain reproduced posteriorly in the buttock.


provocative-tests/

Assesses for dysfunction of sacroiliac joint pathology, with possible

involvement of posterior SI ligament

How to perform:

Patient lies in lateral recumbent position with a pillow between the knees.

The examiner stands behind the patient and places one hand on top of the other

directly over the patient’s iliac crest, exerting a steady downward pressure.

Positive test: Pain reproduced


provocative-tests/

Assesses for pathology of hip

joint, iliopsoas spasm, or

sacroiliac joint dysfunction

How to perform:

The patient lies supine. While

stabilizing the contralateral ASIS

with the cephalad hand, the

examiner moves the leg being

tested into hip and knee flexion,

hip abduction, and hip external

rotation.

Positive test: The patient’s pain is

reproduced and/or the tested leg

does not abduct below the level

of the straight leg.

http://lumbar-spine-special-test.blogspot.com/

Helps distinguish between lumbar

spine and SI joint dysfunction.

How to perform: Pt is supine with the

leg being tested hanging off the edge of

the table. The patient actively flexes

the other leg at the hip and knee.

While helping stabilize the opposite

pelvis to keep the patient on the table,

the examiner applies overpressure to

the leg being tested to put it into

further extension and adduction.

*Note- Always test the unaffected side

first

Positive test: Reproduction of pain

Indicates SI joint problem, pubic

synthesis instability and/or L4 nerve

root lesion.

Source: http://lumbar-spine-special-test.blogspot.com/

Determines which movements (flexion or

extension) increase or decrease reported

symptoms and whether centralization is

occurring

How to perform:

First note the patient’s baseline symptom locations

in the standing position, with emphasis on the

most distal symptoms.

Instruct the patient to bend forward as far as

possible and return to starting position. Record any

effect the movement has on the symptoms.

Repeat 10 – 12 times, then have the patient report

any lasting change in location or intensity of

symptoms.

Repeat the assessment with standing extension,

recumbent flexion, and prone extension

Test extension in both prone and

standing positions

Test flexion in both supine and

standing positions www.drtimspeciale.com

www.braceability.com

www.osteoinfo.com.au

Positive test: Referred pain moves from a

distal to a more proximal location

(centralization)

Indicates that pain is being caused by internal

disk disruption

When centralization does occur, it is normally

related to a single direction of movement

(flexion vs extension). This indicates that

symptoms will likely improve with continued

flexion- or extension-based exercises as part of

the patient’s rehabilitation program.

Seated Flexion Test +

Sacral base is deep, ILA is

posterior/inferior on same side

Sacral base is deep, ILA is

posterior/inferior on opposite side

Sacral Shear

(SI joint problem)

Sacral Torsion

(L5/S1 and/or muscle problem)


right right left sacral sulcus is deep:

L/R Sacral

Torsion

left right left right left right

R/L Sacral

Torsion

L/L Sacral

Torsion

R/R Sacral

Torsion

left


sacral sulcus is deep:

LSE

left right

LSF RSE RSF

If the seated flexion test is negative, the following are possible: 1. No sacroiliac dysfunction (i.e., the patient is

normal)

2. Bilateral flexion or extension

3. The test could be a false negative caused by iliosacral compensation.

ILA equal

Bilateral positive seated flexion test

Sulci deep

Good spring test BILATERAL SACRAL

FLEXION

Sulci shallow

Poor spring test BILATERAL SACRAL

EXTENSION

1. Patient lies on side with axis side down (left

side if L/L torsion) with torso rotated so that

he is face down (modified Sims position).

2. Flex patient’s hips until motion is felt at the

lumbosacral junction

3. Physician is seated behind the patient and

drapes the patient’s legs off the side of the

table over the physician’s cephalad leg (as

shown in picture) so as to induce sidebending

and engage the sacral axis (left sacral oblique

axis if L/L torsion).

4.Cephalad hand monitors at the superior pole

while the caudad hand guides sidebending

until the sacral base starts to rotate in the

opposite direction (rotate to the right for L/L

torsion)

4. While continuing to monitor with the

cephalad hand at the superior pole, ask the

patient to lift his legs toward the ceiling

against your equal counterforce for 3-5

seconds.

5. Repeat 3-5 times, each time re-engaging a

new restrictive barrier. Then retest for

symmetry.

Source: Jones 2009

1. Patient lies on side with axis side down

(left side if R/L torsion) with torso rotated

so that he is face up.

2. Grasp patient’s inferior arm and pull

through to further rotate his torso. Flex

patient’s hips until motion is felt at the

lumbosacral junction

3. Drop the patient’s superior leg off the

table to induce sidebending and engage the

axis (left sacral oblique axis if R/L torsion).

4. While monitoring superior pole with

cephalad hand, ask the patient to lift his

superior leg toward the ceiling against your

equal counterforce for 3-5 seconds.

5. Repeat 3-5 times, each time re-engaging a

new restrictive barrier. Then retest for

symmetry.

www.hal.bim.msu.edu

Monitor sacrum at the middle transverse axis, abduct

left leg to about 15 degrees to disengage the

sacroiliac joint.

Internally rotate the hip to further gap the posterior

sacroiliac joint.

Heel of hand is on the left ILA, pressing anteriorly.

Encourage inhalation, resist exhalation.

Repeat for a total of 3-5 cycles.

Retest.

Source: Jones 2009

Inhalation:

Curves flatten,

sacrum

counternutates

Exhalation:

Curves

accentuated,

sacrum nutates

Monitor sacrum at the middle transverse

axis, abduct to about 15 degrees to

disengage the sacroiliac joint.

Externally rotate the hip to further gap the

anterior sacroiliac joint.

Heel of hand is at the left side of sacral

base, pressing anteriorly (other hand may

monitor on the PSIS)

Encourage exhalation, resist inhalation.


Retest.

Source: Jones 2009

Abduct both legs to about 15 degrees to


Internally rotate both hips to further gap

the posterior sacroiliac joint.

Heel of hand is on the central portion of

the apex of the sacrum, pressing

anteriorly.

Encourage inhalation to bring the sacral

base posterior and superior

(counternutation), resist exhalation.


Retest.

Source: Jones 2009

Abduct both legs to about 15 degrees to


Externally rotate both hips to further gap

the anterior sacroiliac joint.

Heel of hand is on the central portion of

the base of the sacrum, pressing

anteriorly.

Encourage exhalation to bring the sacral

base anterior and inferior (nutation), resist

inhalation.


Retest.

Source: Jones 2009

Positive standing flexion

test

ASIS superior

ASIS medial

PSIS lateral

Sulcus wide

INFLARE INNOMINATE

PSIS inferior

Sulcus deep

Leg length

shorter

POSTERIOR INNOMINATE ROTATION

PSIS superior

Sulcus equal

Leg length

shorter

SUPERIOR INNOMINATE

SHEAR

ASIS inferior

ASIS lateral

PSIS inferior

Sulcus equal

Leg length

longer

INFERIOR INNOMINATE

SHEAR

PSIS superior

Sulcus shallow

Leg length

longer

ANTERIOR INNOMINATE

ROTATION

PSIS medial

Sulcus narrow

OUTFLARE INNOMINATE

Pubic Rami

Ramus superior

SUPERIOR PUBIC SHEAR

Ramus inferior

INFERIOR PUBIC SHEAR

Rami equal

& tender

COMPRESSED PUBIC

SYMPHYSIS

Iliosacral Muscle Energy, Paul R. Rennie, D.O., F.A.A.O., 050906

The side with the positive standing flexion test determines the

landmarks used to diagnose the iliosacral dysfunction.

Therefore, if the standing flexion test is positive on the right, the

right ASIS, PSIS, sacral sulcus, and leg are used to determine

the diagnosis.

1. Patient is supine with the feet off the end of the table.

2. Physician places their thigh up to the contralateral foot (non-dysfunctional side) to stabilize the pelvis and then holds the patient’s leg (dysfunctional side) just above the ankle.

3. The leg is abducted to about 10-15° to loose-pack the SIJ.

4. The hip is then internally rotated to close-pack the hip joint.

5. The physician pulls on the leg while the patient performs a series of about three to four inhalation and exhalation efforts.

6. During the last exhalation effort the patient is asked to cough while simultaneously the leg is pulled in a caudal direction.

7. Assess that proper release is obtained.

Iliosacral Muscle Energy, Paul R. Rennie,

D.O., F.A.A.O., 050906

1. Patient is prone with the physician standing on the same side as the dysfunction.

2. The patient’s foot is placed between the physician’s knees and then the patient’s knee is stabilized with one hand while the other hand is placed on the patient’s ipsilateral ishial tuberosity.

3. The leg is abducted to about 10-15° to loose-pack the SIJ.

4. A cephalad force is placed on the ipsilateral ishial tuberosity while the patient performs a series of deep inhalation and exhalation efforts.

5. Additionally, the patient attempts to straighten the ipsilateral arm (that is holding on the table leg) which results in a caudal force through the trunk.



1. Patient is supine with the physician standing on the side of the dysfunction.

2. The pelvis is shifted to the edge of the table being sure to maintain stability.

3. Physician’s legs are utilized to hold the freely hanging leg.

4. Physician places one hand on the opposite innominate to stabilize the pelvis while placing the other hand over the distal femur on the dysfunctional side.

5. Mild hip extension stretch to the barrier is applied.

6. The patient performs hip flexion muscle effort for three to five seconds.

7. The physician takes-up the “slack” in the myofascial movement and repeats this process until proper release is obtained.


D.O., F.A.A.O., 050906

1. Patient is supine with the physician standing on the opposite side of the dysfunction.

2. The patient has the dysfunctional hip and knee flexed while the physician slightly internally rotates the hip rolling the pelvis to the opposite side.

3. Physician places the middle and ring fingers around the PSIS and the heel of the hand to the ishial tuberosity.

4. The pelvis is placed back on the table and a superior and medial force is applied against the ishial tuberosity.

5. Physician resists three to five efforts of three to five second muscle effort for the patient to straighten the leg in a caudal direction.

6. The physician takes-up the “slack” in the myofascial movement and repeats this process until proper release is obtained.


D.O., F.A.A.O., 050906

1. Patient is supine with the hips and knees flexed and feet flat on the table and together.

2. Physician stands at the side of the table holding the patient’s knees together.

3. Physician resists the patient’s attempt to abduct both knees for a three to five second period of time.

4. Physician now places the forearm between the patient’s knees.

5. The patient adducts against the physician’s counterforce two to three times for up to three to five seconds until release is felt at the pubic symphysis.


1. Patient is supine with the physician standing on

the opposite side of the dysfunction with the hip

and knee flexed.

2. Physician places the heel of the hand on the

ishial tuberosity with the fingers monitoring

motion at the SIJ.

3. The dysfunctional innominate is taken to the

barrier in flexion, external rotation, and

abduction (engagement of the barrier and loose-

packing the SIJ).

4. Physician exerts a cephalward and lateral force

on the ishial tuberosity while the physician

resists three to five efforts of three to five

second muscle effort for the patient to extend

the leg against resistance.

5. The physician takes-up the “slack” in the

myofascial movement and repeats this process

until proper release is obtained.

6. This is similar to the treatment for inferior pubic

shear excepting the loose-packing of the SIJ and

cephalward and lateral force on the innominate.


D.O., F.A.A.O., 050906

1. Patient is supine with the physician standing on the same side as the dysfunction.

2. The patient’s sacrum is brought to the edge of the table.

3. The patient’s leg is placed between the physician’s knees while the pelvis is supported with a hand placed over the contralateral innominate.

4. Physician’s other hand is placed over the distal femur above the patella to push the hip toward anterior rotation.

5. Physician resists patient’s effort to flex the hip through a series of contractions of three to five seconds.

6. This treatment is similar to the superior pubic shear except that here the sacrum is the fixed point on the edge of the table versus the innominate.



D.O., F.A.A.O., 050906


2. Physician flexes the hip and knee rolling the pelvis to the opposite side.

3. Physician monitors the medial side of the PSIS and then the pelvis is brought back to the table to rest on the physician’s monitoring hand.

4. Physician’s other hand adducts the femur to the internal rotation barrier while maintaining lateral traction on the PSIS.

5. Patient attempts to abduct and externally rotate the hip with three to five muscle contractions for three to five seconds with the slack in the tissues taken up between the contraction intervals.



D.O., F.A.A.O., 050906


2. The patient’s hip and knee is flexed with the ipsilateral foot placed on the contralateral knee (below patella).

3. Physician places one hand over the contralateral innominate to stabilize the pelvis and places the other hand over the medial side of the knee on the dysfunctional side, externally rotating the hip until a barrier is engaged.

4. The physician resists three to five efforts of three to five second muscle contractions for the patient to internally rotate the leg against resistance, taking up the slack in the tissues between the contraction intervals.



D.O., F.A.A.O., 050906

T10-L5 may be treated with HVLA using the

“lumbar roll” technique.

Flexion, extension, or neutral lesions can all

be treated in the same lateral recumbent

position

The technique can be performed with the

posterior transverse process down (i.e., the

patient is laying on the same side as the

posterior transverse process) or posterior

transverse up (i.e., the patient is laying on

the opposite side as the posterior transverse

process)

The only modification is which direction the

patient’s inferior arm is pulled

1. Patient should be in the lateral recumbent

position with the physician standing in front of the

patient.

2. Flex the patient’s legs until you palpate motion at

the level of somatic dysfunction.

3. Straighten the patient’s inferior leg and add

slight hip extension.

5. Hook the patient’s superior foot in the popliteal

fossa of the inferior leg.

6. Position patient’s arm according to the type of

dysfunction and which transverse process is up (see

chart below).

7. Place cephalad forearm anterior to the patient’s

shoulder and caudad forearm on the patient’s iliac

crest, with cephalad hand monitoring at the level of

dysfunction.

8. Use caudad forearm to rotate the patient’s hip

forward until you feel lockout at the level of

dysfunction.

9. Instruct the patient to take a deep breath in and

exhale.

10. At end exhalation, apply HVLA thrust by

rotating the patient’s pelvis forward and toward the

table.

11. Retest the range of motion.

http://4.bp.blogspot.com/-NRV-

VkpXE2s/URPL2nCs7kI/AAAAAAAAAlI/

pV2F021Sya0/s1600/1DLumbarLateralRecumbentThrust.jpg

http://4.bp.blogspot.com/-NRV-VkpXE2s/URPL2nCs7kI/AAAAAAAAAlI/





Jones J. Muscle energy treatments: Sacral shears, sacral torsions.

Presented at Touro University Nevada College of Osteopathic Medicine

2009. Henderson, NV.

Rennie P. Iliosacral (innominate) muscle energy pre-lab. Presented at

Touro University Nevada College of Osteopathic Medicine 2009 by Claire

Galin, DO. Henderson, NV.

Savarese R. OMT Review. 3rd

edition. March 2003.

Aubrey Taow, DO 2016 FOMA Convention February 19, 2016valuable tools in diagnosing and treating low...

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