1. Sacral Diagnoses Stuart Williams D.O. Chairman & Associate Professor
Osteopathic Manipulative Medicine
Spring test + = non-neutral of sacrum base posterior bilateral sacral extension
negative spring test = neutral and sacral base anterior
Motion Testing:
Spring: - (It springs!)
Sphinx: - (improves with extension)
Spring: + (It does not spring!)
Sphinx: + (findings worsen with extension)

2. Spring Test
Purpose: To be an indicator of whether you are dealing with a sacral Oblique Axis that is a
Forward Torsion (Neutral)
Backward Torsion (Non-Neutral).
vs.

3. Spring Test
1. Find sacral base
2. Place heel of hand over Lumbosacral junction
3. Spring in an Anterior motion
4. Results:
a. Positive test = If there is NO springing allowed = Non-neutral condition (AKA Backward torsion)
b. Negative test = If there is springing allowed = Neutral condition.

4. Symmetry improves: negative test, neutral mechanics
Worsening asymmetry: positive test, non-neutral mechanics
Good test when having difficulty determining if you have neutral or non-neutral mechanics

5. Sacral Base Anterior
Name: Sacral Base Anterior, Bilateral Sacral Flexion
Lateralization: Does NOT matter.
Spring test: Negative
Landmarks:
Sacral Base: Bilaterally (B/L) Anterior
Sacral Sulcus: B/L Deep
ILA: B/L Posterior
STL: B/L Tight
Motion:
Sacral Base: B/L +
ILA: B/L –
Ant Ant+
Deep Deep
Post - Post-

7. Direct Respiratory Force for Sacral Base Anterior
Patient is prone with doctor at side of table
Doctor places heel of hand on the ILAs, applying downward pressure
Patient inhales, holding his/her breath in inhalation for as long as possible
During inhalation apply a continuous anterior force on ILAs exaggerating sacral extension
Resist sacral flexion during exhalation (hold in sacral extension)
Repeat as necessary
Recheck
Nicholas p. 268

9. Sacral Base Posterior
Name: Sacral Base Posterior, Bilateral Sacral EXTENSION
Lateralization: Does NOT matter.
Spring test: Positive
Landmarks:
Sacral Base: Bilaterally (B/L) Posterior
Sacral Sulcus: B/L Shallow
ILA: B/L Anterior
STL: B/L Loose
Motion:
Sacral Base: B/L –
ILA: B/L +
Post Post -
Shallow Shallow
Ant Ant +

10. Bilateral Sacral Extension
Patient prone, physician on dominate eye side.
Place the thenar eminence of the treating hand over the sacral base .
Abduct both legs until motion is felt by the palpating hand (~ 20), & then internally rotate the legs.
Instruct pt to exhale fully & hold it.
Exert a downward pressure over the sacral base while pt. inhales, resisting sacral extension.
The pressure is maintained for 3 – 5 seconds while gapping the SI joints bilaterally.
This may be accomplished by bending the patient’s knees 90  & gently internally rotating the patient’s abducted legs.
Repeat above 2-3 times & recheck.

11. Direct Respiratory Force for Sacral Base Posterior
Patient is prone, doctor at side of table
Doctor places fingers on the sacral base, applying equal downward pressure to both sides
Patient rests on his/her elbows – sphinx position
Patient exhales completely and holds while doctor encourages anterior motion of the sacrum
Repeat as necessary
Recheck
Nicholas P. 269

12. Vertical Axis Diagnosis: less common
Name: Left Sacral Margin Posterior
Lateralization: Matters NOT. Always call on Posterior side.
For Left Sacral Margin Posterior:
Landmarks:
Sacral Base: L Posterior
Sacral Sulcus: L Shallow
ILA: L Posterior
STL: L Tight
Motion:
Sacral Base: L –
ILA: L –
P –
Shallow
P -
How could we treat this?

14. Findings for Unilateral Sacral Flexion (Sacral Shear)
The sacral base on the side of the significantly inferior ILA will generally be anterior: FLEXED
The ILA will be significantly inferior (& posterior!)
{Sacrotuberous ligament will be pliable and under less tension than the contralateral side.}
Anterior
Posterior
Markedly
Inferior
Right unilateral sacral flexion

15. Motion Testing for Unilateral Sacral Flexion (Sacral Shear)
There will be no motion at the inferior ILA - it is locked down
The base on the same side is likely to have adequate motion
There is generally good motion at any of the other locations but the motion is not likely to “add up” or
+/-
+/- A -
P/I
(we can’t use our paper model for this one!)
(No Axis.)

16. Supine, Direct, HVLA Unilateral Sacral Flexion (Sacral shear) and Upslipped Innominate
Block inferior ILA with pt hand, wallet, towel, or wedge
Grasp leg above ankle and abduct until SI joint is gapped
Internally rotate leg to point of SI gapping
Apply traction and then perform a swift tug (can use ME as in upslipped esp in geriatric pt.)
right sacral shear
Previously taught

18. Prone, Direct, Springing Sacral shear and upslipped innominate
May stand or sit as shown, on same side as shear
Find amount of abduction that gaps joint and internally rotate leg (see pdf and video)
Thenar eminence on inferior ILA, other hand on top of it
Pt breathes in; at height of inhalation - spring sacrum in an anterior/ superior direction
left sacral shear
This may be a muscle energy technique if you ask the patient to use their
abductors to pull the leg on the affected side towards midline. Usual ME technique -
Or have them hold to the point of air hunger with an inspiratory hold.

20. Unilateral Sacral Extension
This is very rare, but I am adding it for completeness sake.

21. Unilateral Sacral Extensions
Findings:
Rare
L Base P
L sulcus shallow
L ILA ant/markedly superior
STL loose
Spring: may be positive (no spring!)
Motion:
Sacral Base: L R +/-
ILA: L +/ R +/- S P- A
+/-
+/-
A/S
+/-
P/I
ASIS compression test + on L in this example.

22. Unilateral Sacral Extension
Patient prone, physician on dysfunctional side.
Place the thenar eminence of the treating hand over the sacral base of the dysfunctional side of the sacrum.
Abduct ipsilateral leg until motion is felt by the palpating hand (~ 20), & then internally rotate the leg.
Instruct pt to exhale fully & hold it.
Exert a downward pressure over the sacral base while pt. inhales, resisting sacral extension.
The pressure is maintained for 3 – 5 seconds while gapping the SI joint on the side of the dysfunction.
This may be accomplished by bending the patient’s knee 90  & gently internally rotating the patient’s abducted leg.
Repeat above 2-3 times & recheck.

23. Neutral Oblique Axis
L on LOA
R on ROA
Tx:
Laying
Seated

24. Left Neutral Sacral Oblique Axis Somatic Dysfunction
Name: L on LOA, RL on LOA, L Forward Torsion
Seated Flexion: Positive on R (rec use for confirmation)
Landmarks: if calling on L side as lateralized
Sacral Sulcus: L Shallow
Sacral Base: L Posterior
ILA: L Post./ Inf.
STL: L Tight
Motion Testing:
Spring: - (It springs!)
Sphinx: - (improves with extension)
L5: NSLRR
Sacral Base L - R +
ILA: L +/- R +/-
L5: SLRR
A +
P+/-
Neutral - Right Oblique Axis Findings:
Name: R on ROA, RR on ROA, R forward torsion
Lateralization: Right
Landmarks:
Sacral sulcus: L deep
Sacral base: L anterior
ILA: R Post/Inf.
STL: R tight
Motion Testing:
Spring: -
L5: SRRL
Sacral Base: L +
ILA: R +/-
Left Right
Midline

25. Right Neutral Sacral Oblique Axis Somatic Dysfunction
P+/- A+
L5: SLRR
Name: R on ROA, RR on ROA, R Forward Torsion
Seated Flexion: Positive on L (confirmatory)
Landmarks:
Sacral Sulcus: R Shallow
Sacral Base: R Posterior
ILA: R Post./ Inf.
STL: R Tight
Motion Testing:
Spring: -
Sphinx: -
L5: NSRRL
Sacral Base L + R -
ILA: L +/- R +/-
Left Right
Midline

26. Neutral Sacral Rotation on the Same Oblique Axis: Ex: L on LOA Prone, Physiologic response: Operator springing, ME, or Resp. force, or combine activating forces.
Patient L lateral recumbent and physician facing patient
Side of oblique axis toward table
With knees bent, flex hips to greater than 90 degrees with knees off table
Physician seated, support patient’s knees with thigh
While monitoring lumbosacral junction (or sacral base), instruct patient to hug table (We LOVE neutrals!) until motion localized at lumbosacral junction
Flex to > 90°
Put him on his left side
Tell him to hug the table
Flex knee to 90 degrees  flattens lordosis
Flexed. Rotate left. Sidebent left.
(rotating L at lumbar = rotate right at sacrum)
See if base comes posterior
KEEP AXIS THE SAME
Create a: R on LOA

27. Neutral Sacral Rotation: L on LOA (Rotated Left on a Left Oblique Axis) Prone, Physiologic response: Operator springing, ME, or Resp. force
With forces localized at lumbosacral junction, grasp spinous process of L5 and pull away from table. You may also simply monitor the R sacral base to be sure it is moving posteriorly.
Apply activating force to the patient’s feet toward floor to localize sidebending while monitoring sacral base opposite of axis
LVMA springing ME
Resp. force
Can utilize a combination of the above forces.
Repeat activating force until adequate motion felt at sacral base
Recheck

28. Neutral Sacral Rotation: Rotated Left on a Left Oblique Axis: L on LOA Sitting, Direct, articulatory, Pt. coop.
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
Seated good for preggo women
CHANGING THE AXIS ON THIS ONE!!
L on LOA so instead of creating R on LOA  you create a R on ROA
Sidbend R and rotate L = R on ROA

29. Non-neutral Oblique Axis
L on ROA
R on LOA
Tx:
Laying
Seated

30. Left Non-Neutral Sacral Oblique Axis Somatic Dysfunction
Name: R on LOA, RR on LOA, L Backward Torsion
Lateralization: Right (use for confirmatory)
Landmarks: calling Left lateralization in this example
Sacral Sulcus: L Deep
Sacral Base: L Anterior
ILA: L Ant./Sup.
STL: L Loose
Motion Testing:
Spring: + (It does not spring!)
Sphinx: + (findings worsen with extension)
L5: confirmatory FRLSL
Sacral Base L - R +/-
ILA: L + R +/-
L5: RLSL
P+/-
A+
Left Right
Midline

31. Right Non-Neutral Sacral Oblique Axis Somatic Dysfunction
Name: L on ROA, RL on ROA, R Backward Torsion
Lateralization: Left (use for confirmatory)
Landmarks: if patient lateralized Right
Sacral Sulcus: R Deep
Sacral Base: R Anterior
ILA: R Ant./ Sup.
STL: R Loose
Motion Testing:
Spring: +
Sphinx +
L5: FRRSR
Sacral Base L +/- R -
ILA: L +/- R +
L5: RRSR
P+/-
A+
Left Right
Midline

32. Sacral Rotation on the Opposite Oblique Axis (Ex: R on LOA) Tx: Lateral Recumbent, Direct Physiologic Response, Respiratory force, Springing, ME Kimberly Manual A, P
Patient lateral recumbent and physician facing patient
Side of oblique axis toward table
With knees bent, flex hips to less than 90 degrees with knees off table
Draw shoulder on table forward so patient’s torso faces upward to induce rotation to lumbosacral junction
Reverses rotation
Physician seated, support patient’s knees with thigh
Keep the axis
Put on side of the axis
Non-neutrals do not like the table
Monitor at L5 or at the base
Bend knees less than 90 degrees because he wants neutral mechanics
SL RR
L on LOA to fix R on LOA

33. Sacral Rotation on the Opposite Oblique Axis (Ex: R on LOA) Tx: Lateral Recumbent, Direct Physiologic Response, Respiratory force, Springing, ME Kimberly Manual A, P
With patient’s knees balanced on thigh, apply activating force on feet toward floor
Sidebending maintains axis
Repeat activating force until adequate motion felt at sacral base
LVMA springing ME
Respiratory force
Reassess
SL RR
Create L on LOA to fix R on LOA

34. Sacral Rotation of the Opposite Oblique Axis ( Ex: R on LOA) Tx: Sitting, Physiologic Response, ME Kimberly Manual: B, P
Patient seated and physician behind patient
Use thumb to monitor for motion at sacral base on opposite side of diagnosed oblique axis
Opposite hand grasps shoulder on opposite side of oblique axis
Guide patient into extension, rotation away from axis, and sidebending toward axis
Instruct patient to gently try to bend to the side away from the axis while physician provides counterforce
Patient then relaxes and physician moves to new barrier
Reassess
THIS IS DIFFERENT
Pt is: SL RR
Tell pt to straighten up
This is the SAME as the previous slide just in a seated position
Use NEUTRAL MECHANICS to fix the non-neutral

35. Pelvis Diagnosis

36. Lateralization Tests The lateralizing tests :
standing flexion test (hamstrings, innominates, sacrum, spine)
May be more specific to ilium motion on the sacrum:
iliosacral motion
2. seated flexion test (innominates, sacrum, spine)
Not influenced by hamstrings
May be more specific to sacrum motion between ilia:
sacroiliac motion
3. compression test (innominates & sacrum only)
Not influenced by spine
Often considered most specific

37. Standing Flexion Test
Note the motion in the last 20 degrees of flexion
Positive test - PSIS moves superiorly on side of dysfunction at the end range of motion…Iliosacral dysfunction…
HOWEVER this could be a False positive
Could be tight hamstrings on contralateral side

38. Seated Flexion Test Pt seated with legs at 90o
Eliminates the influence of the lower extremities sacroiliac dysfunction
Pt seated with legs at 90o
Feet flat on floor or supported by ladderback stool
Doc places thumbs on
undersling of the PSIS.
Pt bends forward at the waist SLOWLY reaching between knees

39. ASIS Compression Test
Have the patient lie supine. The patient is then asked to raise his/her bottom up off the table and then set it back down again. *
Doctor Stands with head and shoulders centered over the patient. Dominant eye centered over patients pelvic region**
Contact the ASIS
GENTLY Stabilize one ASIS while applying pressure at a 45 degree angle to the other ASIS
Positive test - restricted movement of the SI joint > “brick like” limited motion
Negative test - a sense of give or resilience => bounce or spring like motion, should sense on release as well as compression.
*This is done to help them center their weight on the table.
**(this is to help eliminate the effects of eye and hand dominance)

40. Landmarks-Call on side of lateralization.
Supine:
ASIS: S/I
Pubic Symphysis: S/I & A/P
Medial Malleoli: S/I
Prone:
PSIS: S/I
(Ischial Tuberosity S/I)
Write these down & record. Don’t try to “assume” a diagnosis while you are palpating. Trust your thumbs.

41. Innominate Diagnoses:
Left Anterior Rotation
Findings
Left ASIS relatively inferior
Left PSIS relatively superior
S: pubic symphysis
H: acetabulum
X: inferior transverse axis

42. 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 pubic shears and innominate flares).
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.” (Use ½ your strength)
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.

44. ANTERIOR INNOMINATE PRONE DIRECT MUSCLE ENERGY
EX: Left Anterior Innominate.
1. Pt. prone and D.O. on side of dysfunction.
2. Extremity hangs freely off table.
3. Flex pt’s hip and knee. Grasp lower leg to do this.
4. Place pt’s foot flat against your thigh.
5. Other hand on posterior surface of sacrum.
6. Grasp knee & further flex hip & knee.
7. Lift pt’s knee & “squat” to raise foot superiorly. (rotates innominate posteriorly.)
8. “Push foot against my knee.” (Maintain isometric counterforce.)
9. After tissues relax, flex hip to rotate innominate posteriorly to new barrier.
10. Repeat until best motion. (usu. 3 times). Recheck.

46. Innominate Diagnoses:
Left Posterior Rotation
Findings
Left ASIS relatively superior
Left PSIS relatively inferior
S: pubic symphysis
H: acetabulum
X: inferior transverse axis

47. 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.

49. POSTERIOR INNOMINATE: PRONE- MUSCLE ENERGY
1. Pt. supine & D.O. on side opposite dysfunction.
2. Cephalad hand- hypothenar eminence on iliac crest & PSIS.
3. Caudad hand- grasp distal femur just above knee.
4. Extend hip to move innominate anteriorly to the restrictive barrier.
5. “Pull your knee down toward the table.”
6. Sense that force is localized at SI joint.
7. Extend extremity to new restrictive barrier.
8. Repeat until best motion. (usu. 3 times.)
9. Recheck.

51. Pubic Symphysis Somatic Dysfunctions
Pubic Symphysis Superior/Inferior Shear
Can be a SD by itself (rare)
May often follow innominate SD (innominate ant/post rotation, up/down slipped innom).
Can follow sacral shear
Common in obstetrical patients due to relaxin
Pubic Symphysis Anterior/Posterior Shear
Relatively rare, usually caused by trauma
Compression of the Pubic Symphysis
Everything looks even, just tenderness, restricted motion

54. Innominate Inflare/Outflare Somatic Dysfunction
Lateralized ASIS is closer to the umbilicus than the non-lateralized side
i.e., with a left inflare, there is a shorter distance between the umbilicus and left ASIS than the right ASIS
Outflare:
Lateralized ASIS is further away from the umbilicus than the non-lateralized side
i.e., with a left outflare, there is a longer distance between the umbilicus and left ASIS than the right ASIS
Innominate inflare/outflare somatic dysfunction is not involved in inferior transverse axis mechanics
It occurs about a vertical axis

55. INNOMINATE INFLARE TREATMENT
1. Pt. supine and D.O. on dysfunctional side.
2. Hip & knee partially flexed, foot on table close to buttocks.
3. Stabilize opposite ASIS.
4. Move knee laterally abducting thigh to innominate’s restrictive barrier.
5. “Move knee toward middle of table.”
6. Wait 3-5 seconds & abduct thigh to new restrictive barrier.
7. Repeat until best motion. (usually 3 times.)
8. Recheck.

57. INNOMINATE OUTFLARE TREATMENT
1. Pt. supine and D.O. on dysfunctional side.
2. Knee & hip partially flexed.
3. Grasp patella with one hand and hook fingers of the other hand over medial margin of involved PSIS.
4. Move knee medially adducting thigh to restrictive barrier.
5. “Move knee outward.”
6. Wait 3-5 seconds and adduct thigh to new restrictive barrier.
7. Repeat until best motion. ( ave. 3 times.)
8. Recheck.

59. Innominate Diagnoses:
Left Inferior Pubic Shear
Findings
Left ASIS relatively inferior
Left PSIS relatively superior
S: pubic symphysis
H: acetabulum
X: inferior transverse axis
Usually has an associated L anteriorly rotated innominate. Pubic shears can be only superior or inferior without innmominate rotations. This is usually from some type of trauma.
Inferior Pubic Shear (physiologic)
Tissue texture changes in the pubic region
Superior surface of pubes is inferior (“step off sign”)
Usually a positive flexion test on the side of the dysfunction
Inferior glide of the pubic ramus is present
Superior glide of the pubic ramus is restricted
Tenderness to palpation over the pubic symphysis. May have symptoms of frequency and burning on urination even without infection
May be seen with an innominate anterior.

60. TREATMENT: INFERIOR PUBIC SHEAR
1. Pt. supine and D.O. on side of dysfunction.
2. Flex lower extremity at knee and hip an abduct thigh to gap pubic symphysis.
3. Place knee against chest, cup cephalad hand against ASIS, grasp ischial tuberosity with other hand. (rotates innominate posteriorly to carry pubic symphysis superiorly.)
4. “Push knee toward end of table against my chest.”
5. Move innominate to new restrictive barrier.
6. Repeat until best motion. (approx. 3 times.)
7. Recheck.

62. Innominate Diagnoses:
Left Superior Pubic Shear
Findings
Left ASIS relatively superior
Left PSIS relatively inferior
S: pubic symphysis
H: acetabulum
X: inferior transverse axis
Usually associated with a posteriorly rotated innominate if physiologic.
Superior Pubic Shear (physiologic)
Tissue texture changes in the pubic region
Superior surface of pubic ramus is superi9or (“step off sign”) on the dysfunctional side
ASIS compression test is positive on the dysfunctional side
Usually a positive flexion test on the side of the dysfunction
Superior glide of the pubic ramus is present
Inferior glide of the pubic ramus is restricted
Tenderness to palpation over the pubic symphysis. May have symptoms of frequency and burning on urination even without infection.
May be seen with an innominate posterior.

63. SUPERIOR PUBIC SHEAR
1. Pt. supine and D.O. on dysfunctional side between table & leg.
2. Stabilize opposite ASIS.
3. Have pt. move laterally until ischial tuberosity at edge of table.
4. Abduct knee to gap symphysis.
5. Extend thigh. (rotates innominate anteriorly and carries symphysis inferiorly.)
6. “ Lift knee toward ceiling.” Wait 3-5 seconds.
7. Extend thigh to new barrier.
8. Repeat until best motion. (av. 3 times.)
9. Recheck.

65. Innominate Diagnoses:
Left Upslipped Innominate
Findings
Left ASIS relatively superior
Left PSIS relatively superior
S: pubic symphysis
H: acetabulum
X: inferior transverse axis
Nonphysiologic.
No axis!
Symphysis and Ischial tuberosity could also be superior in more severe cases.

66. Supine, Direct, HVLA Sacral shear and upslipped innominate
Block inferior ILA with pt hand, wallet, towel, or wedge
Grasp leg above ankle and abduct until SI joint is gapped
Internally rotate leg to point of SI gapping
Apply traction and then perform a swift tug
May also use ME (localize or tx)
right sacral shear

67. Downslipped Innominate (Respiratory Cooperation)
Dx - (+) StFT on affected side with all ASIS, PSIS, and pubic rami inferior
aka, Inferior Pelvic Shear
Tx – With patient lying on unaffected side and knees bent, apply an upward & lateral force on the ischial tuberosity & the ilium.
Have patient take several deep breaths while you resist, & then advance cephalad as able & repeat.
Recheck your findings.
(Another treatment option is to have
the patient hop on the affected leg
several times and then recheck)

69. Lumbar Spine

70. Assess lordosis ROM Forward Bending Backward Bending (Seated)
Trunk rotation (seated)
Lumbar sidebending

71. RED REFLEX  use two/three fingers and drag down the back
RED REFLEX  use two/three fingers and drag down the back. (TP, spine, TP)
Red should go away quickly
If the red stays longer than you should assume there may be acute somatic dysfunction
Note: skin changes tenderness and prominence differences

72. Soft Tissue Techniques
Prone- Direct, Kneading
Lateral Recumbent- Direct, Kneading
Prone- Direct Stretching
Lateral Recumbent- Direct, Kneading and Stretching

73. Lumbar Paraspinal Muscles - Soft Tissue: Prone, Direct, Kneading

74. Soft Tissue: Lateral Recumbent-Direct-Kneading

75. Prone—Direct—Kneading and Stretching: 4913.11B

76. Lateral Recumbent—Direct– Kneading and Stretching: 4913.11C

77. Segmental Dx: L1 – L5 Sagittal Sidebend Rotate
Should be: SL RR (then do not need to do saggital (should be normal/none)
If the pt. is SL RL (or SR RR) then you should do the sagittal (flexion/extension) to see which non-neutral they are in.

78. Multiple Plane - Type I Mechanics
Diagnosis
Rotation palpation
With the patient prone or seated, place your thumbs on a lumbar vertebra’s transverse processes located an inch lateral to the spinous process;
Push anteriorly on the right TP to induce rotation left. Push anteriorly on the left TP to induce rotation right;
Restricted rotation left = rotated RIGHT; restricted rotation right = rotated LEFT

79. Multiple Plane - Type I Mechanics Diagnosis
Sidebending palpation
Thumbs then slide medially to base of spinous process near the intervertebral space inferior to the lesioned body
Apply motion testing in a medial direction
Sidebending named for way it wants to go
Concave side indicates direction of SB
Sagittal plane
Also check for non-neutral dysfunction
(does it get better/worse in flexion/extension)

80. Practice Diagnose your partner for a Type 1 Mechanic dysfunction
N SxRy
Diagnose your partner for a Type II Mechanic dysfunction
F/E RxSx

81. Treatment – Type I Mechanics
Indirect technique
Balanced ligamentous tension (BLT)
Seated
Supine
Direct technique
Muscle Energy (ME)

82. Common Diagnostic Findings
Multiple Plane - Type I Mechanics
Common Diagnostic Findings
Example for N SL RR
SB left presents
approximation of L TP to segment below
separation of R TP from segment below
Left SB motion freedom, right SB motion restriction
Rotation right presents
right TP posterior
left TP anterior
right rotation freedom left rotation restriction

83. Multiple Plane - Type I Mechanics
Indirect Treatment (BLT)
**Sitting, indirect, pt coop, resp force D**
Physician sits behind pt
Physician contacts ipsilateral TP of segment below the rotated side (right TP of L4)
Physician contacts contralateral TP on lesioned segment (left TP of L3)
Pt is instructed to drop arm to induce further SB to float segment
Pt is instructed to BB( “lean back”) to float the segment
Pt instructed in respiratory force
Recheck
Example for L3 N SLRR

84. MULTIPLE PLANE-Type 1 Mechanics Indirect Treatment (BLT)
MULTIPLE PLANE-Type 1 Mechanics Indirect Treatment (BLT) **Supine, indirect, pt cooperation, respiratory force G**
Pt is supine and the physician sits on the side of rotation (right)
Physician reaches under pt and places pad of finger on the contralateral TP of dysfunctional segment – when applying anterior pressure will induce rotation into dx (right)
Pt instructed to “arch back” or “flatten back” as needed to balance ligamentous tension in sagittal plane
Apply anterior tension against contralateral TP (induce rotation) and apply traction to area gently creating SB (left)
Pt instructed in respiratory force
Repeat – avg 3 times
Recheck
DX: N SLRR

85. DX: N SLRR

86. Practice
Indirect Techniques – Type I (neutral)
Seated
Supine

87. Multiple Plane - Type I Mechanics
Direct Treatment (ME)
**Sitting, direct, ME / HVLA A or B **
N SLRR
Salute rotated side
R hand behind neck
L hand on R elbow OR
Put pt. in position as palpated
place pt. hands to help you undo the setup
Goal: pt. position opposite of diagnosis
After
Before

88. Multiple Plane - Type I Mechanics
Direct Treatment (ME)
**Sitting, direct, ME / HVLA A or B **
Standing behind the seated patient, place your thenar eminence on the posterior TP(s)
Reach across the upper chest with your other hand and arm to control the pts shoulders/trunk (under)
Move trunk into the SB then rotation barriers until you feel movement at the restricted segments. Extend to localize in sagittal plane
Ask pt to straighten the trunk/shoulders for 3-5 sec. against your equal resistance
Allow FULL relaxation ( 3-5 sec) and then slowly move to new restrictive barrier as you push anterior into the posterior TP(s)
Repeat 3-5 times
Recheck

89. Multiple Plane - Type I Mechanics Direct Treatment (ME)
Multiple Plane - Type I Mechanics Direct Treatment (ME) **Supine, direct, ME / HVLA F **
Pt is supine and physician stands on pts side of rotation (right)
Pt is instructed to flex knees and hips and place feet flat on table creating lumbar flexion
Physician grasps the spinous process of dysfunctional segment and pulls segment towards him/her to induce rotation into restrictive barrier (left)
Physician uses other hand to pull pts feet toward him/her creating SB into restrictive barrier (right)
Pt is instructed to “ put feet back on table while physician offers isometric counterforce for 3-5 sec
Allow full relaxation ( 3-5 second) then positions to new barrier
Repeat 3-5 times
Recheck
DX: N SLRR

90. Multiple plane – Type II Mechanics
Non-neutral Somatic Dysfunction
Vertebral units above and below may exhibit type I (neutral) mechanics.
More painful.
often associated with sympathetic hyperactivity in organs innervated by T12-L2 area.

91. Multiple plane – Type II Mechanics Diagnosis
Ex: F RLSL
Flexion component:
Spinous process approximates the segment above
Spinous process separates from the segment below
Flexion is present
Extension is restricted
Rotation component
L transverse process relatively posterior
R transverse process relatively anterior
Spinous process shifted to the right
L rotation is present
R rotation is restricted

92. Multiple plane – Type II Mechanics Diagnosis
Ex: F RLSL
Sidebending component:
Approximation of L transverse process to segment below.
Separation of R transverse process from segment below.
L sidebending is present.R sidebending is restricted.
Tenderness to palpation over the supraspinous ligament or articular capsules. Usually more painful than neutral.
Diagnosis:
Check with extension and flexion
Usually a non-neutral is found at the apex of a neutral curve or beginning/end of a neutral curve

94. Multiple Plane - Type II Mechanics Direct Treatment (ME)
Multiple Plane - Type II Mechanics Direct Treatment (ME) **Sitting, direct, ME B **
Standing behind the seated patient, place your thenar eminence on the posterior TP/ or contacts SP
Reach across the upper chest with your other hand and arm to control the pts shoulders/trunk (over)
Move trunk into the rotation/SB/ sagittal plane barriers until you feel movement at the restricted segments.
Ask pt to straighten the trunk/shoulders for 3-5 sec. against your equal resistance
Allow FULL relaxation ( 3-5 sec) and then slowly move to new restrictive barrier as you push anterior into the posterior TP(s)
Repeat 3-5 times
Recheck

95. Patient salutes rotated side
Operator’s arm over patient’s shoulder

96. Thumb contacts SP
(can also place heel of L hand over L TP).

97. NN
(F) RLSL
contact the left TP with the heel of left hand

98. Operator applies force to localize sidebending

99. Right hand grasps right proximal humerus and guides patient’s lumbar spine into R sidebending,
R rotation, and FB/BB as needed to take all 3 planes to their restrictive barriers.
Patient then turns or bends against D.O. while D.O. maintains isometric counterforce.
Wait!! (3-5 seconds at least)
Sidebend, rotate, BB/FB (tiny increments to new barrier.)
Move to new barrier. Repeat 3x. Recheck.
(HVLA directed ant/sup with heel of left hand at same time with one body movement.)

100. Multiple Plane - Type II Mechanics Indirect Treatment (BLT)
Multiple Plane - Type II Mechanics Indirect Treatment (BLT) **Supine, indirect, pt cooperation, respiratory force E **
Pt supine with his/her hips and knees flexed and feet flat on table, physician on opposite side of rotation
Physician reaches under the pt and grasps SP of involved vertebra to induce rotation into SD to the point of BLT
Physician instructs pt to move your shoulders and feet to side of rotation/side bending – into dx to the point of BLT
Pt instructed to “arch back” or “flatten back”
Pt instructed in respiration
Repeat – avg 3 times
Recheck

102. Steps for successful manipulation of the spine
Diagnose accurately.
Decide what treatment to use, indications, contraindications, conditions of the patient, direct or indirect method.
Apply the principles which guide the method chosen (localize to the point of ease or localize at the restrictive barrier in all 3 planes.)
Hold the patient securely, but lightly and comfortably.
Sense the patient relaxed and the forces localized.
Use the correct direction and dosage of activating force.
Recheck to determine the change produced