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Scoliosis and Short Leg – An Osteopathic Manipulative Medicine Approach
Jonathon R. Kirsch, D.O., C-NMM/OMM Associate Physician Neuromusculoskeletal Medicine/OMM Marshfield Clinic Stevens Point Center 4100 N. Hwy 66 Stevens Point, Wisconsin, 54482 Presenting at WAOPS Fall Seminar, Sept , 2015
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Learning Objectives Describe postural strain, its effects on the body, its diagnosis and treatment. Classify and Differentiate various types of scoliosis, and discuss its clinical significance. Discuss management and OMT for scoliosis. Describe diagnosis, implications, and appropriate heel lift protocol for anatomical short leg. Discuss gait, postural mechanics, and related clinical presentations for the sacrum and pelvis regions.
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Learning Objectives Describe the use of radiographic studies in postural diagnosis and management. Discuss and interpret the “Cobb Angle” measurement from an AP radiograph of the thoracolumbar spine. Discuss and interpret sacral base unleveling measurement from an AP radiograph of the pelvis. Discuss and interpret lumbosacral angle and pelvic index measurements from a lateral postural x-ray.
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Learning Objectives Discuss strategies for osteopathic manipulative treatment in functional scoliosis. Perform structural exam of spine, noting asymmetry and lateral curvature. Observe and document changes in asymmetries with the use of a heel lift before and after OMT. Diagnose and treat somatic dysfunction in the pelvis, sacral, lumbar, and thoracic regions.
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Materials Needed for This Lab
12 pieces of 20lb copy paper Your hands
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Construct a Heel Lift Start with 12 pieces of standard copy paper (20lb) Take 3 pages and stack them together. Fold in half Fold in half again Fold in half a third time Tape the open edges closed with scotch tape. You now have a 1/8 inch heel lift for this lab! Stack 2 of these together for ¼ inch lift. Stack 4 together for ½ inch lift (total of 12 pages)
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The Consequences of Unlevel Foundations…
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Postural Homeostasis Postural changes take place in order to coordinate visual, vestibular, and kinesthetic input Each person responds to asymmetric postural stress uniquely Changes occur in a more predictable pattern in the lumbopelvic region due to unique biomechanics. like the righting reflex due to proximity to center of gravity
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Effects of Postural Strain - Bone and Joint
Wolff’s law Wedging of vertebral body and exostoses (spurs). Can result in modified function and increased calcium deposition Increased functional demand + asymmetry joint degeneration Long term radiographic postural studies: progressive postural decline Lateral curves more likely to evolve if leg-length difference > 10 mm. Wolff’s law: under chronic stress (like exaggerated postural curves), bone will remodel itself over time to become more resilient to the stressor. Degenerative arthritis targets of hip joint of long leg; accompanied by tenderness over that side’s greater trochanter.
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Postural Observation Asymmetry Rotoscoliosis screening
Body position and alignment Spaces or gaps from one side to the other Key landmarks Rotoscoliosis screening Levelness of key landmarks In static position In dynamic position (when patient bends forward) Compare gaps between arms & trunk.
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Ideal Posture: Sagittal Plane
Center of gravity should pass through following points: Just anterior to lateral malleolus Just posterior to mid-knee Femoral head Anterior third of sacral base Middle of body of L3 Humoral head External auditory meatus Failure to maintain this perfection shifts burden of weightbearing to soft tissues and joint facets dysfxn.
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Iliolumbar Ligament Strain
Anterior Sacral Rotation Strains portions labeled “1”. Posterior Innominate Rotation Strains portions labeled “2”
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Iliolumbar Ligament – Postural Effects
One of the first structures involved in postural decompensation Exhibits tenderness, edema, pain Groin pain Hip pain
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Scoliosis-defined as a pathological or functional lateral curve; an appreciable lateral deviation in the normally straight vertical line of the spine. (Dorland). Scoliosis
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Demographics 10 in 200 children by age 10-15 are diagnosed
1 in 200 children have clinical symptoms Curves progress during rapid growth Boys and girls are affected equally initially, but in girls is 3-5 times more likely to progress It usually stabilizes after the child stops growing. If the child stops growing with less than a 40 degree Cobb angle, adult progression is rare.
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Naming by Side Named according to the Convexity Dextroscoliosis-curve that is sidebent left, scoliosis/convexity is to the right. Levoscoliosis-curve that is sidebent right, scoliosis/convexity is to the left.
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Classification By Cause
Idiopathic (70-90% scoliotic curves) Unlevel sacral/cranial base Sagittal plane biomechanics Other unknown causes Congenital 75% are progressive Acquired Short leg syndrome, Psoas syndrome, Osteomalacia, Inflammation, Irradiation, Sciatic irritibility, Healed leg fracture, Following hip fracture
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Double Major Scoliosis (most common)
Classify by LOCATION: Double Major Scoliosis (most common) Balanced curve Subject to Degeneration at Cross Over Areas of Curve
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Single Thoracic Scoliosis
Cosmetically noticable Heart and Lungs in jeopardy with progression of scoliosis
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Single Lumbar Scoliosis
Associated with Arthritic change
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Junctional thoracolumbar scoliosis
Less Common Associated with Arthritis often (due to long length of curve)
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Classification By Reversibility
Functional vs. Structural Functional curves go away with side bending, rotation, or forward bending Structural curves are fixed and do not reduce with side bending, rotation, or lift therapy
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Classification By Severity
Mild Scoliosis (less than 20 degrees). Moderate Scoliosis (between 20 and 45 degrees). Severe Scoliosis (between 45 and 70 degrees). Very Severe Scoliosis (Over 100 degrees).
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Cobb Angle Angle of Lines across the top of the superior vertebral segment, and Across the bottom of the inferior vertebral segment of a spinal scoliotic curve The perpendicular lines intersect to form an angle (“Cobb angle”) FOM fig 43.11 FOM
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Management in Mild Scoliosis
Periodic Monitoring OMT Physical Therapy Orthotics / Lift Therapy Education
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OMT for Scoliosis - Overview
Treat lumbar and pelvic somatic dysfunction. Assess for anatomic leg length difference. Long restrictor muscle stretch for side of concavity (Hypertonic m. stretching) Postural exercises for retraining Possible heel lift for anatomical short leg.
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Management in Moderate Scoliosis (between 20 and 45 degrees)
Bracing – consider in curves 20 to 50 degrees OMT, Exercise, Physical Therapy Orthotics Education Electrical stimulation (debatable efficacy)
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Management in Severe Scoliosis (between 45 and 70 degrees).
OMT Exercise, Education Orthotics Bracing Electrical stimulation (debatable efficacy) Surgery as possible last resort (1 in 1000 cases) Curves greater than 45 degrees Prevents heart and lung complications At >75 degrees the distortions may also cause dangerous changes in the heart or lungs
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SpondyloListhesis
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DEFINITION Forward displacement of one vertebra over another
usually L5 over S1 Clinical Presentation: Back pain plus or minus leg pain and tight hamstrings Radicular pain more common in adult Painful extension L5 nerve deficits Classifications Type I – Dysplastic congenital deficiency of neural arch of L5 (most commonly) or uppersacrum insufficiency of superior sacral facets 2 girsl: 1 boy ratio Type II – Isthmic II-A: lytic fatigue fracture of pars articularis; most common < 50 y/o II-B: elongated but intact parts; probably due to repeated microfractures II-C: acutely fractured pars; Hx of severe trauma Type III – Degenerative at apophyseal joints due to long-standing intersegmental instability 4 female: 1 male 3 black: 1 white common at L4 not seen before age 40, rare b/w 40-50 Type IV – Traumatic due to Fx in other areas of the bony hook than the parts heals w/ immobilization Type V – Pathologic generalized or localized bone disease neoplasm, osteogenesis imperfecta, Paget’s, etc. Hereditary Factors Observations that argue against direct inheritance of spondylolisthesis: 1. there is an increased incidence w/in family groups, but individuals exhibit different types of spondylolisthesis 2. infants rarely reported to have spondylolysis (pre-spondylolisthesis) incidence increases after they become upright and continues up to age 20 Hereditary factors are those that predispose the region to instability e.g spina bifida lack of posterior support may concentrate postural weightbearing forces in the area subluxation of L5 Genetics can also predispose pts to stress fracture of pars interarticularis L5 slides forward (isthmic spondylolisthesis) Type III: Degenerative spondylolisthesis (aka: pseudo-spondylolistheis) is 2-3x more common in African Americans greater L5-S1 stability Low pelvic index for age 60 higher incidenc of sacralization of L5 and/or block-shaped L5 vertebrae lower incidence of posterior defects than the general population increased instability at L5 instability higher in the lumbar spine
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Classification Types Type I: Dysplastic Type II: Isthmic
Insufficiency of articulatory process Type II: Isthmic Defect in Pars Interarticularis Or Fracture Type III: Degenerative Changes in apophyseal joints Type IV: Traumatic Fracture other than in pars interarticularis Type V: Pathologic Secondary to Disease
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Meyerding Grading System
For each one quarter that the upper vertebra is displaced forward on the vertebra below I (1-25%) II (25-50%) III (50-75%) IV (more than 75%) Progression Fastest ages 9-15 Rare progression over age of 20 System is commonly used, quick, and clinically relevant Progression over age 20 rare - Especially in pts with a sclerotic buttress on the anterior lip of the sacrum
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Risk of Cauda Equina Can occur in isthmic spondylolisthesis above grade II (50% anterior movement) Can occur in dysplastic spondylolisthesis above grade I (25% anterior movement)
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Postural Etiology Hyperlordosis transfers weightbearing from the vertebral bodies onto the articular facets Higher incidence is seen in gymnasts due to increase in backward bending.
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Microtrauma Etiology Repetitive lumbosacral motion
Ex. Weight lifters, soldiers carrying backpacks, and college football linemen Frequent postural stress, especially during growth spurt, contributes to the syndrome
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Diagnosis Diagnostic Testing Radiography (Ferguson’s Angle)
History (½ of patients asymptomatic) Physical examination Spinal palpation Neurologic testing Preventative care depends on early and accurate diagnosis
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Palpatory Findings Anteriorly located spinous process
Sacral base motion exhibits laxity in anterior motion Paraspinal tissues – tissue texture changes and tenderness Iliolumbar ligament = bilateral tension and subjective tenderness Patient may present with lateral thigh and/or groin pain
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Radiographic Findings
Lumbolumbar or lumbosacral lordotic angles are objective measurements of lumbar lordosis Hyperlordosis is significant in patients with sagittal plane postural problems
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Lumbosacral Angle (AKA Feguson’s Angle or Sacral Base Angle)
Is a measure of lumbosacral lordosis Angle between the top of the sacral base, and the horizontal plane. Normal is degrees. Reference line Line A Line B
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Conservative Management
Treatment addressing the underlying instability, spinal mechanics, and patient homeostasis. Stretch hamstrings, improve lumbar and abdominal strength, and flexibility Promote anti-lordotic posture Boston Brace for antilordosis (9-12 mo.) OMT, orthotics, patient education Exercise - stabilize the lumbosacral region, diminish the lumbar lordosis, flexion-type only
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Goals of OMM in Spondylolisthesis
Reduce Lumbar Lordosis and somatic dysfunction Help promote lympathic drainage Promote optimal stability of weightbearing posture Directed at support structures, eg. Pelvis Correct Sacral Base Unleveling with heel lift orthotic Thoracic spine and thoracolumbar junction Quadratus lumborum and the iliolumbar ligament Avoid HVLA**
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Short Leg Syndrome and Lift therapy
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Anatomic versus Functional
Anatomic Short Leg- One leg is anatomically shorter than the other. Functional Short Leg- one leg appears shorter than the other but is secondary to pelvic dysfunction or other structural imbalance or scoliotic curve.
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Effects of Short Leg Pelvis side shifts and rotates toward long leg
Innominate rotates anterior on side of short leg or posterior on side of long leg Foot of long leg pronates, internally rotating lower leg Lumbosacral angle increases by 2 to 3 degrees Lumbar spine has convexity on short leg side (sidebending away from short leg) Compensatory curves are generally type 1 neutral.
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Lateral Curves over Time
Sacral base unlevels in coronal plane Curve forms in one spinal region - C-shaped curve Over time, other spinal curvatures develop S-shaped curve Thoracic curve may develop with convexity opposite the lumbar spine Lumbar spine side bends away from and rotates toward the low sacral base (explain pic) C-shaped curve – single long scoliotic curve in the lumbar or lumbothoracic spine S-shaped curve – The shoulders and the greater trochanteric planes are typically depressed on the same side as the depressed sacral base
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Sacral Mechanics with Short Leg
In short leg there will be lumbar sidebending, affecting sacral mechanics through the L5-Sacrum mechanical relationship. Lumbar sidebending to the left (see figure) if chronic, will be associated with a left oblique axis sacral somatic dysfunction Lumbar sidebending convexity is usually on the side of the short leg (DiGiovanna)
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Sacral Motion in Gait Left rotation on a left oblique axis
Left oblique axis is engaged L5 RR Right rotation on a right oblique axis Right oblique axis is engaged L5 RL Example: When the left leg is weight bearing, then the left axis of the sacrum is engaged. Spinal column sidebends to the left (the weight bearing side) The weight pins the upper pole of the sacrum on the weight bearing side. As free lower extremity swings forward, it carries the free pole of the sacrum anteriorly, creating rotation of the sacrum about the Oblique Axis. We call this a left rotation on a left oblique axis. This is normal.
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Sacral Base Unleveling – Associated Findings
If sacral base is inferior on one side in the coronal plane, and If this is due to leg length inequality, Then the following are typically inferior on the side of inferior sacral base: Greater trochanter of femur PSIS iliac crest
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Innominate Dysfunction in Short Leg
Innominate rotation dysfunction can give rise to functional short leg, as acetabulum is anterior to mid-line of bone. Anterior rotation contralateral short leg Posterior rotation ipsilateral short leg Anterior Innominate ASIS inferior PSIS superior Anatomic short leg can give rise to compensatory innominate rotation dysfunction. Short right leg Right anterior innominate Short left leg Left anterior innominate
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Short Leg Diagnosis Check for sacral and innominate shear.
OMT should be directed to all related somatic dysfunctions prior to diagnosis Observe iliac crest height, femoral head height, sacral base leveling, degree of scoliotic compensatory curvatures, angle of the scapula, etc… Obtain standing postural x-ray
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AP Postural Xray Interpretation
Vertical lines are drawn from femoral heads A sacral base line is constructed across the top of the sacrum, to femoral head lines Intersection of sacral base line and femoral head lines gives femoral head height differential (C and C’ in diagram) The sacral base unleveling is reported as the height differential between the measurements taken at the line intersecting the vertical transecting the femoral heads. Measurements using this protocol report accuracy to within ± 0.75mm, when other methods report errors of ± 2mm.
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Treatment Short leg Syndrome
OMT directed to the spine, pelvis, LE’s, all associated musculature, ligaments and fascia. If leg length discrepancy is apparent after somatic dysfunction addressed, order standing postural x-ray series. If the Standing Postural Series reveals a femoral head discrepancy of >5mm., consider heel lift therapy.
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Lift Therapy Initiated to help body return to better structural alignment and function The patient’s postural mechanisms are reeducated toward ideal posture Paraspinal muscle tension and other spinal physiologic parameters become more symmetrically normalized Level foundation of vertebral column
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“Flexible Spine” Mild to Moderate Strain
Spine is flexible No more than mild to moderate strain is noted in the myofascial system Begin with 1/8-inch lift and lift at a rate no faster than 1/16 of an inch per week, or 1/8 of an inch every 2 weeks.
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“Fragile Patient” Arthritic, osteoporotic, aged, having significant acute pain, etc. Begin with 1/16-inch lift and lift no faster than 1/16 of an inch every 2 weeks.
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Sudden Loss of Length Recent sudden loss of leg length on one side, (eg. following fracture or a recent hip or knee replacement surgery) Patient had a level sacral base before the fracture or surgery Lift the full amount that was lost.
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Lift Therapy in Children
Monitor children with lifts closely Wolf’s Law may cause longer leg to grow faster Check bone length on X-ray if possible and monitor leg lengths Fryette found that in his pediatric patients the short leg would grow to equal the long leg with lift therapy, over time.
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Heel Lift Therapy Final lift is ½- ¾ amount of total discrepancy, unless is immediately after a surgery where height was lost, and full amount of change can be corrected. A maximum of ¼ inch should be lifted inside of shoe, if greater, lift outside of shoe. If need to lift > ½ inch, should also lift sole of shoe to prevent compensatory inominate rotation.
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Standing postural asymmetry examination Seated postural examination
Perform a structural exam with attention to coronal plane asymmetry and lateral curves Gait evaluation Standing postural asymmetry examination Seated postural examination did anything change? Have your instructors check your findings
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Standing Sidebending Test
Slide hand down thigh toward knee Look at curve in thoracolumbar spine Smooth curve? Abrupt changes in curve?
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Gross Spinal Flexion Test
With standing forward flexion, observe thoracic spine for any rotational humping on one side. This indicates a lateral curve For eg., a hump on the left signifies a lateral group curve in the spine, which is sidebending right, with rotation left. Rotoscoliosis
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STANDING FLEXION TEST The patient stands - feet are hip’s width apart
- knees extended The physicians's - fingers on the iliac crest - thumbs thumbs rest on the posterior superior iliac spines (PSIS). Ask the patient, “Bend forward slowly without flexing the knees” Physician feels and observes the superior movement of the PSIS (The side which moves first and furthest indicates restriction of the iliosacral joint on the same side.)
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Sidebending: Mid-Thoracic Region (T4 to T8)
The hands of the examiner are placed on the shoulders over the acromion process. A downward and medial pressure is exerted, depressing the shoulder on one side and then on the other. Check for asymmetry in ease of shoulder movement in the inferior direction, on each side.
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Rotation - (T8 to T11) Place hands are on the shoulders
Rotate the trunk to both sides. Check for symmetry or asymmetry. Note: The lower thoracic spine has greater rotation than the upper due to rib attachments that restrict the upper region.
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Hip flop Patient supine
Knees up, feet on table, lift buttocks off table, then down again, and straighten legs
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Medial malleolus position
Grasp ankles bilaterally, with thumbs Inferior to medial malleolus on each side Make sure lower extremities are lying straight Assess relative levelness of medial malleolus (superior/inferior) Record position of Side of Lateralization
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ASIS Levelness
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Pubic Tubercle Levelness
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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. Contact the ASIS Stabilize one ASIS while applying pressure at a 45 degree angle to the other ASIS Positive test - restricted movement of the Sacroiliac joint -> rock like motion Negative test - a sense of give or resilience => bounce or spring like motion *This is done to help them center their weight on the table. **(this is to help eliminate the effects of eye and hand dominance)
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SLR (hamstring tension)
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Setting the Pelvis (Prone)
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Quad tension and Psoas tension
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PSIS
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Ischial Tuberosity Gluteal curve- where thigh joins gluteus muscle.
Palms approximately 4” apart. Push superiorly, slightly laterally until you run into a very firm bone (ischial tuberosity). Is the ischial tuberosity superior or inferior on the lateralized side?
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Lumbosacral Spring Test
Patient Prone Physician at Side of Table Place Heel of Hand over Lumbosacral Junction (L5-S1) Keep arms straight, and lean with body Spring Several Times – Negative Test is a Mobility to Springing (motion is felt at joint) Positive Test is Restriction to Anterior Springing
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Decreased Sacral Base Asymmetry indicates a Negative Test
SPHINX TEST Decreased Sacral Base Asymmetry indicates a Negative Test Increased Sacral Base Asymmetry indicates a Positive Test
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Sacral Motion Testing Motion testing over the 4 Corners of the Sacrum
Place thumb on the right sacral base. Keep arms extended. Spring anteriorly Place thumb on the left sacral base. Keep arms extended. Spring anteriorly Place thumb on the right ILA. Keep arms extended. Spring anteriorly Place thumb on the left ILA. Keep arms extended. Spring anteriorly Record (+), (-), or (+/-). + means a sense of resiliency, springs back - means little to no motion, bricklike +/- means some motion Record your findings on your Sacral Motion Testing Worksheet.
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Make Your Diagnosis of Somatic Dysfunction
Psoas/Hamstring Femoroacetabular Innominate Sacrum Lumbar Thoracic Short Leg Syndrome? Functional Anatomic
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Effects of Short Leg Pelvis side shifts and rotates toward long leg
Innominate rotates anterior on side of short leg or posterior on side of long leg Foot of long leg pronates, internally rotating lower leg Lumbosacral angle increases by 2 to 3 degrees Compensatory curves are generally type 1 neutral.
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Scoliosis and Lateral Curves
Treatment Section
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OMT for Scoliosis - Overview
Treat sacral and innominate dysfunction. Assess for anatomic leg length difference. Thoracic and lumbar type 2 dysfunctions Thoracic and Lumbar treatment of type 1 group curves. Long restrictor muscle stretch for side of concavity (Hypertonic m. stretching) Postural exercises for retraining Possible heel lift for anatomical short leg.
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Application of Heel Lifts
Pre-OMT Application of Heel Lifts
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Exaggerate the lateral curves
Add 1/8 inch lift under the heel of the side with the high iliac crest Observe what happened Did the asymmetry increase ? Did the compensatory curves change ? Add ¼ inch lift and repeat observations.
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Use lifts to level the iliac crests and sacral base
Place lifts under the heel of the side with the low iliac crest, place enough lift to level iliac crest. Observe what happened Did the asymmetry increase ? Did the compensatory curves change ? Observe what happened to the primary and secondary curves
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OMT Part One: Innominate / Hip
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Hamstring Stretch – For Shortened Hip Extensors, 4613.11A
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Iliopsoas Stretch
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Muscle energy for posterior innominate technique
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Muscle energy technique for anterior innominate technique
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OMT Part Two: Lumbo-Sacral
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For Non-Neutral Dys.
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Lumbar HVLA – for Neutral Dys.
11. A high velocity, low amplitude thrust is applied antero-superiorly to the pelvis while providing counterforce through the patient's shoulder 12. Recheck Dx: L3-5NSlRr
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KIM 213A
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TX: Unilateral Sacral Flexion (Sacral Shear) DX: Left unilateral sacral flexion
KIM 213A
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KIM 216A
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Recheck Symmetry
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Repeat the standing postural examination on your partner
Did your findings change? What changed Is your partner a candidate to be evaluated for possible lift therapy?
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Use lifts to level the iliac crests and sacral base
Place lifts under the heel of the side with the low iliac crest. Place enough lift to level the iliac crests. Observe what happened Did the asymmetry decrease? Did the compensatory curves change?
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What is next? Does your partner still have a low iliac crest on standing, after OMT? Did you successfully treat all the somatic dysfunctions that could be contributing to the high/low iliac crest/sacral base? Is it an acute or chronic problem? (recent lower extremity surgery, or long term?) Is further work-up for short leg indicated?
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Sources Steinberg, Akins, Baran, Orthopaedics in Primary Care, 3rd ed., LWW, Philadelphia, 1998, Pg Kuchera and Kuchera, Osteopathic Principles in Practice, 2nd ed., revised. Greyden Press, Columbus, Ohio, 1994. Ward, editor, Foundations for Osteopathic Medicine., 2nd ed., LWW, Philadelphia, PA 2003 Chila, Foundations for Osteopathic Medicine, 3rd Ed., 3rd ed., LWW, Philadelphia, PA 2010, pg The Muscle Energy Manual, Mitchell, Fred L., Volume 3, pg An Osteopathic Approach to Diagnosis and Treatment, DiGiovanna, pp Kimberly, P., Outline of Osteopathic Manipulative Procedures, “The Kimberly Manual”, 2006 ed., (2008 update), Walsworth Pub Co, Marceline, MO., 2008.
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