OMM #40
April 8, 2003, 8am
Cedric Pratt
Dr. Fotopoulos
Page 1 of 3
Not checked
Treatment of Type II Sacral Somatic Dysfunction
Most of the information that was presented at the beginning of this lecture should be
review. Dr. Fotopoulos
Remember your axis for rotation. eg. vertical, horizontal, oblique, and AP axis
1. SACRAL MECHANICS
 Physiologic diagnoses of the sacrum occur in neutral and non-neutral
mechanics:
– In neutral mechanics, the sacrum rotates in the same direction as the
oblique axis (left rotation on a left oblique axis)
– In non-neutral mechanics, the sacrum rotates in the opposite direction of
the oblique axis (right rotation on a left oblique axis)
• Named for upper pole of sacrum
• occur in normal (dynamic) motion as well as pathologic torsions
• Torsions:
– Forward Torsion: (neutral) rotation in same direction e.g. Left rotation on
left oblique axis (Left on LOA)
– Backward torsion (non-neutral) rotation in opposite direction e.g. right
rotation on left oblique axis (Right on LOA)
2. Non-Neutral: Left Oblique Axis Findings
*know findings and landmark because they will be on the exam.
Name: R on LOA, RR on LOA,
Backward Torsion
Landmarks:
Sacral Sulcus: L Deep ( in relationship to the ileum)
Sacral Base: L Anterior
ILA:
L Ant/ Sup
STL:
L Loose
Motion Testing:
Spring:
+ ( no motion at the lumbosacral junction)
L5:
RLSL
Sacral Base L RILA:
L+
R*L5 SB to the L and an oblique axis is created on the L and L5 also rotates
to the L causing the sacrum to rotate to the R. So with backward torsion
you will always have a non-neutral L5.
*findings for a non-neutral right oblique axis would be opposite ( accept
for spring test and sacral base motion testing)
OMM #40
April 8, 2003, 8am
Cedric Pratt
Dr. Fotopoulos
Page 2 of 3
Backward torsion
• Example R on LOA
• Lumbar spine nonneutral: e.g. flexion > 90° with sidebend. RLSL (L5
rotates opposite of sacrum)
• Occurs when right sacral base rotates right (“backward”) and does not
rotate forward
• Sacral findings: R base posterior, left ILA anterior & superior
• Very painful!
3. Review of type II mechanics of the lumbosacral spine
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Again, it is key to remember that sidebending in the lumbar spine creates
the sacral oblique axis ipsilaterally (ie, left sidebending produces a left
oblique axis in the sacrum).
Type II mechanics in the sacrum occur when the lumbosacral region of the
spine is in trunk flexion (Fryette regional extension).
When sidebending/rotation is attempted in the lumbosacral spine in
extreme trunk flexion, one lumbar segment will rotate and sidebend to the
same side.
That force affects the sacrum and induces type II motion (L5 NN RRSR
induces a LoR sacrum)
Recall that in the type II mechanics of the sacrum that one side of the
sacral base moves posteriorly.
The contralateral ILA moves anteriorly
4. Physiologic Response Technique
• Assume a diagnosis of LoR.
• Have patient lay on their right side (on the side of the oblique axis - the
axe always goes into the table)
• flex hips slightly, taking legs off the table. The angle of trunk flexion is
minimal (much less than 90 degrees because you want to make them
RoR and > 90 will create a non-neutral)
• Again, ensure that the knees are off the table, not on the edge of the table
• You now want the lumbar spine to rotate to the left, which results in the
patient’s shoulders facing up towards the ceiling. (patients do not love
non-neutral - NO hugging here!)
• Monitor at the left side of the sacral base and employ one, two, or all three
activating forces: springing, muscle energy, resp. coop.
Non-Neutral sacrum lateral recumbent
• Patient lies on side of axis
• flex knees to allow legs to be off table, but less than 90 degrees
• patient rolls onto back ( this causes lumbar to rotate and sacrum to rotate
the opposite direction
OMM #40
April 8, 2003, 8am
Cedric Pratt
Dr. Fotopoulos
Page 3 of 3
• Doctor applies activating force to legs, either muscle energy, springing, or
respiratory coop
A. Springing = DO springs on leg to induce motion
B. Muscle Energy = DO asks patient to push leg against hand as DO applies
resistance then DO takes leg to new barrier. Repeat
C. Respiratory Cooperation = DO has the patient takes deep breaths and hold
breath while feeling were the leg likes to go
5. The seated physiologic alternative
• Have the patient straddle the end of the table while you stand behind the
patient.
• Assume the diagnosis is LoR
• Duplicating the Physiologic Response technique, we want to maintain the
right oblique axis in the treatment set-up.
• Therefore we will sidebend the patient to the right
• We want the sacrum to rotate to the right on the right oblique axis, so we
will rotate the lumbar spine to the left. (Remember the compensatory
and opposite rotation between the sacrum and the lumbars)
• We want type I mechanics to apply; therefore, we will apply pressure to
the lumbosacral region to increase lordosis.
Technique
• Operator reaches across chest and grasps shoulder on side of axis
(osteopathic salute)
• Operator side bends patient to side of axis (Right side)
• Operator rotates patient opposite direction (to the left)
• Operator slides arm under pt arm
• Operator instructs patient to backward bend to ensure lumbar lordosis
• Operator instructs patient to unwind against resistance
• Operator monitors left sacral base for anterior motion
• readjust & repeat
6. Supine Indirect
• For Neutral - sit on the side of the axis and use the hand closest to pt to
contact sacrum.
• Example - LoLOA - sit on left side of patient and use left hand
• For non-Neutral - sit on side opposite axis and use hand closest to pt. to
contact sacrum
• Example - RoLOA - sit on right side of patient and use right hand
Technique
• Treating a left rotation on right oblique axis
• DO applies tension with thenar eminence on right sacral apex to move it
further anterior
• Patient’s respiratory cycle is monitored to determine greatest sense of ease