Short Course on OMM for the Thoracic Spine, Ribs, Lumbar Spine and Sacrum Jose S. Figueroa, D.O. (Joe) Board CerBfied in PM&R and NMM/
OMM 1 ObjecBves •  Present a perspecBve on the ManipulaBve Methods of Dr. A.T. SBll •  Apply those principles in the SEATED posiBon for the Thoracic Spine, Lumbar Spine, Sacrum and Rib areas •  Sacrum Strain Counter Strain in the Prone PosiBon •  Sacro-­‐Iliac Decompression (Jeffrey PaRerson, D.O.’s Technique) in the Supine PosiBon –  Using a Contract/Relax (modified Muscle Energy) Technique 2 A Note on ManipulaBve Methods of Dr. A. T. SBll InformaBon taken from an arBcle wriRen by Jamie Archer, D.O. (UK) AAO Journal, Volume 21, Issue 4, December 2011, Pages 20-­‐25 3 Dr. SBll Treated Anywhere •  He treated paBents anywhere he could, such as: –  On the Floor –  Against a Tree or Door Jamb –  On a Chair or Stool –  Backed up against a Box of Goods –  With his foot resBng on a Fence •  etc. 4 Dr. SBll’s Treatments Discarded (?) •  He rarely did the same thing twice, which frustrated and confused his students. •  They could not figure out what he was doing. •  This inability to copy Dr. SBll may have been the reason why his delicate precision and long leverages were all but discarded, being replaced by dreaded general treatments, as well as the solitary thrust type of technique. 5 Soothing Treatments •  Dr. SBll insisted that treatments be of a –  Soothing, inhibitory and quie9ng character –  Not a rough manipulaBon •  Which would only serve to increase the inflammatory state of the Bssues 6 Specific Treatments •  Specificity can mean different things to different people. •  A quote from Dr. SBll during the 1920s sums it up: “By specific I do not mean a treatment las9ng three minutes or five minutes, but a treatment, every movement of which has a definite object in view.” •  In other words, osteopathic treatment is not governed by the clock. 7 On Preparing Tissues w/ Soi Tissue Techniques-­‐Prior to “AdjusBng” •  Dr. Arthur Hildreth, a graduate of the first class of the ASO and a personal friend of Dr. SBll’s, recalls how Dr. SBll paid great aRenBon to the soi Bssues as a preliminary to any aRempt at selng a bone (as it was oien called). He would not aRempt a correcBon unBl the soi Bssues had been prepared to the point where the correcBon had a reasonable chance of being maintained.4 This, of course, may take one treatment or many, depending on the case. Philip A. Jackson told the story of Dr. David Clark, an 1898 ASO graduate whose own neck injury was treated by Dr. S9ll every day for three weeks using only soF 9ssue treatment before any correcBon was made.7 8 Treatments Expected to Take Time •  Osteopathy was born during a Bme where the quick fix was not necessarily expected. According to Emmons Rutledge Booth, quick results were oien viewed with suspicion, with paBents fearing that some kind of witchcrai had been worked upon them. Most expected their treatment to take Bme, such that the inns and local residents’ houses were full of paBents for months on end. 9 SBll Technique(?): One Vs. Many Movements per Technique •  If the operator is aiming to change the posiBon of a structure, such as the first rib or clavicle, then a singular movement may well be all that is needed. •  However, if working to reduce deep-­‐seated, soi-­‐Bssue tension around rigid arBculaBons, then a more repe99ous movement is required. 10 SBll Technique(?): One Vs. Many Movements per Technique •  This is also the case if aiming to free congesBon and affect the circulaBon of vital fluids, whether locally, such as in the axilla, or more generally, as may be the case when choosing to use a lymphaBc pump technique. •  The long leverages employed in Dr. SBll’s methods, and their repe99ve nature, target mulBple Bssues during treatment— arguably making it more specific, rather than focusing on a single Bssue as described in the (more recently described) SBll Technique. 11 CombinaBon of Methods of Treatment •  Whatever Dr. SBll did to his paBents, it appears that he used a variety and combina9on of methods rather than just one technique. •  Challenge by the author: I would certainly recommend revisiBng the Old Doctor’s published books and other wriBngs. However, do not just read them—have fun studying them, for they will yield many precious gems. 12 Hilary Haas: OMM Fellow at DMU •  “I have transiBoned from thinking about treaBng the body in a 2 dimensional way where bones rotate, side-­‐
bend, & flex/ext to a more 3 dimensional model. “ •  “The bones have ligaments/tendons/muscles that aRach to them and pull them in many more direcBons than the x-­‐y-­‐z planes. I think it is when we tap into the many soi Bssues at the same Bme that we can truly mimic the movement of the body, move with the body, not force it to move in the 2 dimensional planes we iniBally needed in order to understand the beginnings of moBon.” 13 ApplicaBons of SBll Technique: General Thoughts 1.  Diagnose the somaBc dysfuncBon (SD) with as much of the joint anatomy in mind as possible 2.  Take the bone away from the restricBve barrier (indirect posiBon) first. –  This may be in ONE OR MORE planes of moBon –  Ex. With a SD in FRlSl •  Reverse Flexion only, or •  Reverse Flexion and Sidebending only, or •  Reverse all components, taking the joint to ERrSr 14 ApplicaBons of SBll Technique: General Thoughts 3.  Then apply a COMPRESSING or a DISTRACTING (or separaBng) FORCE to the joint. Choose the force by –  Asking the pa9ent which feels bePer &/or –  Seeing which one (either compression or distracBon) soFens the 9ssues the most. 15 ApplicaBons of SBll Technique: General Thoughts 4.  Then take the bone through the restric9ve barrier (direct posi9on) with one or many mo9ons (repe99vely) painlessly. –  Ask the paBent if it is feeling OK or if it is hurBng. –  If it is hurBng in any way, choose another movement pathway for the correcBon. 16 ApplicaBons of SBll Technique: General Thoughts 5.  Communicate to insure that they don’t feel uncomfortable with the invasion of their personal space. 6.  Then Re-­‐evaluate the SD to see if it is corrected. 17 ApplicaBons of SBll Technique: Thoracic Spine •  Silng up straight •  Hands Supported –  On a wall or on some other furniture piece –  Easiest if the paBent could straddle the table with their hands on the table 18 Thoracic Spine: Silng up straight Diagnosis and Setup: FRSR 1. Indirect Posi9on with Compression (FRSR) 2. Indirect Posi9on with Distrac9on * Choose the force by: Asking the pa9ent which feels bePer &/or Seeing which one (either compression or distracBon) soFens the 9ssues the most. 19 Thoracic Spine: Silng Up Straight Treatment: FRSR 1. 2. 3. 20 Thoracic Spine: Hands on Table Treatment: T6 FRSR Posterior View 1. 2. 21 Thoracic Spine: Hands on Table Treatment: T6 ESrRr 1. Place paBent indirectly: Extend, Sidebend R, Rotate R AND compression or extension of segment 2. Move paBent to direct posiBon: Flex, Sidebend L, Rotate L AND maintain compression or extension 22 ApplicaBons of SBll Technique: Ribs •  Rib 1 –  Silng up straight •  Ribs 2-­‐12 –  Hands Supported •  On a wall or on some other furniture piece •  Easiest if the paBent could straddle the table with their hands on the table 23 Ribs: Anatomy •  Costovertebral and Costotransverse Joints 24 Ribs: Anatomy •  Upper ribs are horizontal •  Lower ribs angle inferiorly 25 Rib 1: Silng Up Straight Diagnosis 1. Superior aspect Rib 1: High on Right 2. Anterior aspect Rib 1: Anterior on Right Diagnosis: Rib 1 Sidebent LeF, Rotated LeF 26 Rib 1: Silng Up Straight Treatment: R1 RL SL 1. 3. 2. 4. 27 Ribs 2-­‐12: Silng up Straight Treatment: Posterior Right Rib 1. Place hand on posterior rib, distract laterally 3. 2. 28 Ribs 2-­‐12: Silng up Straight Treatment: Anterior Right Rib 1. 2. 29 Ribs 2-­‐12: Hands on Table Treatment: Posterior Right Rib 1. 2. 30 ApplicaBons of SBll Technique: Lumbar Spine •  Silng up straight •  Hands Supported –  On a wall or on some other furniture piece –  Easiest if the paBent could straddle the table with their hands on the table 31 Lumbar Spine: Silng up Straight Treatment: L4 FRSr 1. 2. 3. 32 Lumbar Spine: Hands on Table Treatment: L2 FRSr 1. 2. 33 ApplicaBons of SBll Technique: Sacrum •  Reasoning: –  Just like with Muscle Energy technique, we will use the lumbar spine as a lever •  Silng up straight –  One hand on a sulcus •  Hands supported (on same table or other structure) –  Both hands on the sulci 34 Sacrum: Silng up Straight Treatment: L on R BST 1. Monitor at sacral sulcus 2. Flex lumbars and rotate them to the leF. Thumb presses inferiorly on the leF sulcus to place the 9ssues in an indirect posi9on (following the inferior ILA). Compress or distract the spine. 3. Maintaining compression or distrac9on, extend L-­‐spine and rotate it to the right, press thumb anterior and superiorly. 35 Sacrum: Hands on Table Treatment: L on L FST 1. Extend lumbars and rotate them to the right. Thumb presses inferiorly on the leF sulcus to place the 9ssues in an indirect posi9on (following the inferior ILA). Compress or distract the 9ssues. 2. Maintaining compression or distrac9on, flex L-­‐spine and rotate it to the right, press thumb anterior and superiorly. 36 Sacroiliac (SI) Decompression Using a Modified Muscle Energy Technique 37 Sacroiliac Decompression Using a Modified Muscle Energy Technique •  Reason for treatment: –  Pain at the SI joint, or Hip, or BuRock, or Groin area –  Unable to balance the sacrum or innominate bones with convenBonal techniques •  Diagnosis –  Tender at either the SI joint, PSIS, buRock, groin, etc. –  Hip externally or internally rotated while supine and treaBng the hip rotators do not correct that. 38 Sacroiliac Decompression Using a Modified Muscle Energy Technique Procedure: 1.  PaBent supine 2.  Hip flexed to 90 degrees 3.  Knee flexed 4.  Physician seated on the side of the SI joint to be decompressed 5.  Physician hooks fingers medial to the PSIS (i.e., sacroiliac joint) 39 Sacroiliac Decompression Using a Modified Muscle Energy Technique 6.  Physician pulls laterally on the PSIS while asking the paBent to contract 3 seconds and relax 2 seconds, for a total of 3 to 4 Bmes in 4 to 6 direcBons. The direcBons are: –  AdducBng the hip –  AbducBng the hip –  Flexing the hip –  Extending the hip –  Internally rotaBng the hip –  Externally rotaBng the hip 7.  Re-­‐evaluate: either sacrum or innominates, or hip rotaBon (observaBon while supine). 40 Sacroiliac Decompression Using a Modified Muscle Energy Technique •  Note: –  These movements are to be done in minute amounts. –  These movements are NOT like the classic muscle energy in order to reach a barrier of hip moBon. –  The goal is to DECOMPRESS the SI Joint 41 SI Decompression * 1. AdducBng the hip 2. AbducBng the hip *hand on PSIS, pulling laterally 42 SI Decompression 3. Flexing the hip 4. Extending the hip 43 SI Decompression 5. Internally rotaBng the hip 6. Externally rotaBng the hip 44 Sacrum Tender Points Treated with Strain-­‐Counterstrain Technique 45 Sacrum Strain/Counterstrain “Steps” •  Diagnosis: 1.  Guided by history decide which areas to test 2.  Test a few tender points (TPs) 3.  Decide which one is the worst TP (most tender) 46 Strain/Counterstrain “Steps” Review •  Treatment: 1.  Place paBent in the posiBon of comfort 2.  Ask the paBent if it is 75-­‐100% less tender 3.  Hold for 90 seconds. 4.  SLOWLY return the paBent to a neutral posiBon while paBent remains passive. 5.  Recheck the TP. •  You have NOT removed your finger from the TP during the enBre treatment cycle. 47 Sacrum Tender Points •  To treat these tender points the Dr. needs to push down on the sacrum on areas opposite to the tender point. •  Bradley Klock, D.O.: “Applying skin drag towards the direcBon of the treatment can be more effecBve and it is easier to perform.” 48 1 2 3 4 5 49 Sacrum Tender Point Treatments •  Points 1 lei and 1 right: Push on the opposite side ILA and apply skin drag obliquely towards the mid-­‐lateral thigh. Point 1 50 Sacrum Tender Point Treatments •  Point 2: Push on the apex of the sacrum and apply skin drag caudally. •  Point 4: Push on the base of the sacrum and apply skin drag towards the head. •  Point 3: Perform either the treatment for Point 2 or Point 4. Point 2 Point 4 51 Sacrum Tender Point Treatments •  Points 5 lei and 5 right: Push on the opposite side sacral sulcus and apply skin drag obliquely towards the transverse process of T12. Point 5 52 Strain/Counter-­‐strain •  “To keep this simple and pracBcal, I search for the tender-­‐points; when one is found, I press on the sacrum as far away from the tender-­‐
point as possible.” Lawrence Jones, D.O. 53 Conclusion or “Take Away” Points •  Diagnose with the bony and joint anatomy in mind. •  Take the SD indirectly first in one or more planes of moBon •  Apply compression or distracBon while taking the joint to the barrier of moBon with either one or more (repeBBve) movements •  The paBent should feel good and the area soothed as the physician treats the SD. •  Constantly communicate with the paBent regarding: –  Their symptoms during the procedure and –  Their comfort level with the paBent’s personal space during the procedures. 54 References •  Archer J, D.O. (UK), “Manipula/ve Methods of Dr. A. T. S/ll”, AAO Journal, Volume 21, Issue 4, December 2011, Pages 20-­‐25 •  Glossary of Osteopathic Terminology Usage Guide, 2006: hEp://www.aacom.org/om/
Glossary.doc •  Jones L, et.al. Jones Strain-­‐CounterStrain 55