evening with the faaos - academy of osteopathy

EVENING with the FAAOs

“Something Different”

2018

Name(s) of Presenters: John D. Capobianco, DO, FAAO

Name of College of Osteopathic Medicine Attended: UNECOM

Year of Graduation: 1989

Years in Practice: 27

Year received FAAO: 2002

Name of Presented Technique: Fulford’s Dural Release

Developer/Source: Dr. Fulford’s Visiting Clinician to UNECOM, 1986

Description of Technique: Using ocular motion to undo dural tension

approaching from indirect and direct technique. The movement of the ocular

muscles to the point of insertion at the annulus of Zinn on the sphenoid will

initiate the kinetic chain of events as the dura mater connects to the anterior,

inferior attachment of the cranium at the clinoid processes. Initiation of motion

will “unlock” the tension in the connective tissue of the dura - which will reflect

to the suboccipital musculature (specifically the myodural bridge and the C2/3

caudad to the “Core Link” of the pelvis. It should be noted that the “myodural

bridge” was not in the academic lexicon in 1986. Time permitting, a brief

comparison to Dr. Jones’ cranial approach to the dura mater will be made.

Specific Diagnosis: Somatic Dysfunction of the Reciprocal Tension

Membrane: Headache, Concussion, Post meningeal infection, Emotional Shock.

Patient Position: Supine

Physician Position: At the head of the table, seated

Stepwise description of Technique:

1. The Patient’s position of the head relative to the neck is in

neutral.

2. The physician cradles the occiput with fingers extending into

the suboccipital musculature; thumbs may flare out in a

relaxed fashion but not compressing the mastoid process.

3. The physician asks that the patient’s eyes are closed.

4. The physician actively rotates the patient’s head to the left

and right

5. The physician notes laterality of the quality of freedom and

restriction as opposed to absolute quantitative range of

motion. This is not assessing the AA per se because there is

no complete locking out of cervical rotation; nor is it fully

assessing the OA in the osteopathic nomenclature because

the coronal and sagittal planes are not evaluated. Dr. Fulford

was interested in the motion of the membranes of the

cranium. See image 1 and 2

6. The patient’s head is brought back to neutral; the patient’s

eyes are still closed.

7. The physician gently rotates the patient’s head to the side

opposite to the relative freedom (to the “feather’s edge”

barrier of restriction [note: The term “feather’s edge” was

also not in the academic lexicon when Dr. Fulford taught this

technique]) and then asks the patient to look towards the

freedom as the physician brings the head in an arc of motion

towards the freedom (again, rotation was designated as the

plane of treatment). This would indicate an indirect

component as the patient is looking towards the freedom.

The motion will feel smooth The patient’s eyes are still

closed. See image 3 and 4.

8. The physician repeats this three times.

9. The physician then brings the patient’s head to the freedom

10. The physician has the patient “keep looking towards” the

side of freedom - with the eyes still closed. In lay terms, the

physician will say “look to your left ear” or “look to your right

ear”.

11. The physician now “cranks” the head in an arc of motion to

the restrictive barrier (of rotation). The patient still is looking

towards the side of ease.

12. The physician will find considerably more “tension” during

this “direct” phase of the treatment. The motion will feel

more jagged and hesitant.

13. The physician repeats three times or until the motion is

without restriction. The “tension” will most definitely feel

less within three cycles.

14. The physician brings the head back to neutral and repeats

steps 7 through 11 in the opposite directions, both the

indirect and direct components.

15. The physician reassesses both the quality of the arc of

rotation of head on the neck and the feel in the suboccipital

musculature (in which lies the myodural bridge, the rectus

capitis posterior minor) and the attachments of the dura at

C2 and C3 and distally to sacrum (The term “myodural

bridge” was not in the lexicon in 1986. See image 5)

16. Compare this technique with Jones’ “sphenobasilar”

treatment, especially for cranial torsion.

17. The point is found inferior and medial to the lambdoidal

suture (midway between lambda and the mastoid process)

and upward and obliquely from the inion. See image 6

18. Note: I calculate that about 10 percent of Jone’s original

tender points were of cranial origin. This should be explored.

(See image 7)

19. The physician uses the fronto-occipital hold

20. The physician uses a counterclockwise movement on the

frontal bone as a “counter rotation force” is applied to the

occiput. (See image 8)

21. The patient is supine.

22. Jones does not distinguish between the laterality of the

tender point for the SBS, nor does he specify freedoms or

restrictions. Regardless, if one might assume to compare left

and right and perform the rotary motions as the original text

suggests, a high sphenoid is on the side opposite the occipital

tender point; and if done bilaterally, it will have adjusted the

dura mater, as with the Fulford technique, as an end point,

and symmetrically remove unwarranted stresses in the

connective tissue of the cranium which will not only affect

the five phenomena of the primary respiratory mechanism

but also balance in total body anatomy and physiology.

EVENING with the FAAOs “Something Different”

2018

Name(s) of Presenters: Anthony G. Chila, DO, FAAO DIST, FCA

Name of College of Osteopathic Medicine Attended: KCCOS (KCUMB COM)




Name of Presented Technique: “Without Noise or Motion; In a Continuous or Constant Manner”

Developer/Source: Influence of two (2) Mentors; Personal development

Description of Technique: Continuous analysis of form and function:

Specific Diagnosis:

Patient Position: Standing; Seated; Supine positions

Physician Position: Variable: Change sufficient to analyze patient through clothing; in Standing, Seated and Supine positions


Patient EXPRESSION

Physician OBSERVATION/HEARING

Body WISDOM


2018

Name(s) of Presenters: Dennis J. Dowling, DO, MA, FAAO

Name of College of Osteopathic Medicine Attended: NYCOM




Name of Presented Technique: Rapid Diagnosis of the Shoulder

Developer/Source: Dowling

Description of Technique:

Specific Diagnosis: Shoulder Dysfunction

Patient Position: Seated

Physician Position: Standing behind the patient


1. The patient is seated with hands resting comfortably on the thighs

2. The physician stands behind the patient slightly further to the side that is being examined.

3. The physician places one hand on the shoulder to be examined. The physician places the right hand on the patient’s left shoulder or the left hand on the right shoulder.

4. The physician spreads the fingers of the hand on the shoulder to contact different components of the shoulder:

a. The fifth finger contacts the clavicle at the sternoclavicular joint and notes changes during movement of the examination of the:

i. Sternoclavicular (SC) joint; ii. The first rib articulation with the manubrium;

b. The fourth finger overlies the middle of the clavicle towards the coracoid process and evaluates the Suprahumeral (SH) pseudo joint;

c. The third finger contacts the Acromioclavicular (AC) joint;

d. The second finger overlies the lateral part of the shoulder and evaluates the Glenohumeral (GH) joint;

e. The first finger is oriented backwards and downwards over the rear portion of the shoulder and assesses the Scapulothoracic (ST) pseudo joint.

f. The palm contacts the superior-posterior part of the shoulder and notes the motion of the first rib

5. The physician’s other hand grasps the patient’s arm to be tested at either the patient’s elbow or wrist (Physician’s right hand holds the patient’s right elbow or wrist; Physician’s left hand holds the patient’s left elbow or wrist).

6. The patient remains passive throughout much of the remainder of the movements.

7. The physician then directs the patient’s arm into the following directions and note’s the degrees of motion in each plane as well as the quality of motion:

a. Flexion b. Extension c. External Rotation d. Adduction e. Internal Rotation f. Abduction/Circumduction

8. Each palpating finger can note which shoulder joint or pseudo joint demonstrates restriction of motion.

9. In addition, the following orthopedic tests can be performed: a. Acromioclavicular Joint Compression Test – compress

scapula and the clavicle – positive – laxity and/or pain of the AC joint - Acromioclavicular and/or coracoclavicular ligament sprain

b. Empty Can Test – with the patient’s shoulder abducted to 90°, horizontally adducted 30°, initially with the th e arm externally rotated the physician pushes the arm to the floor and then has the patient internally rotate so the patient's thumb faces the floor and the physician resists the patient's attempts to actively abduct the shoulder and repeats with the opposite shoulder - Weakness and/or pain – tear supraspinatus muscle and/or tendon

c. Yergason Test – during testing of external rotation, the elbow is flexed to 90° and forearm positioned so that the lateral border of the radius faces upward (neutral position) - Examiner resists the patient's attempt to actively supinate the forearm and externally rotate the humerus - Pain and/or snapping in the bicipital groove - Bicipital tendinitis or tear/laxity of the transverse humeral ligament

d. Speed's Test - shoulder flexed to 90°, the elbow fully extended, and the forearm supinated, and the

physician resists the patient's attempt to actively flex the humerus upward - Tenderness and/or pain in the bicipital - Bicipital tendinitis

e. Hawkins–Kennedy Impingement Test – The physician forward flexes the shoulder to 90 degrees and then internally rotates the patient's shoulder - Pain and apprehension during the - shoulder impingement of the supraspinatus or long head of the biceps brachii tendon

f. Piano Key Sign Test (Spring Test) – The Physician applies pressure to the patient's distal clavicle in an inferior direction - Depression of the clavicle when pressure is applied and elevation of the clavicle when pressure is released - Instability of the acromioclavicular joint

g. Active Compression Test (O'Brien's Test) - shoulder in 90° of forward flexion, 30 to 45° of horizontal adduction and maximal internal rotation – The Patient horizontally adducts and flexes the shoulder against physician's manual resistance and is repeated with the patient's arm in externally rotated position - Pain and/or popping present in internally rotated position but absent in externally rotated position - SLAP (Superior Labrum Anterior to Posterior) tear

h. Neer Impingement Test – The Physician grasps and stabilizes the patient's scapula (posteriorly) with one hand and the elbow (anteriorly) with the other hand and then passively and maximally forward flexes the patient's shoulder - Pain and apprehension - Shoulder impingement, particularly of the supraspinatus and biceps long head tendons

10. In addition, by noting resistance in one direction, especially with decreased elastic compliance, it can implicate muscle spasm of the antagonistic muscles:

a. Flexion – resisted by latissimus dorsi, triceps

b. Extension – resisted by pectoralis major and minor, anterior deltoid, biceps brachii

c. External Rotation – resisted by subscapularis, d. Adduction – resisted by deltoids, e. Internal Rotation – resisted by teres major,

infraspinatus, teres minor, f. Abduction/Circumduction – resisted by teres major,

supraspinatus


2018

Name(s) of Presenters: Dennis J. Dowling, DO, MA, FAAO

Name of College of Osteopathic Medicine Attended: NYCOM




Name of Presented Technique: Facilitated Positional Release of the Clavicle

Developer/Source: Stanley Schiowitz, DO, FAAO (approximately 2007)


Specific Diagnosis: Clavicular Shoulder Dysfunction


Physician Position: Standing behind the patient


1. The patient is seated with hands resting comfortably on the thighs

2. The physician stands behind the patient. The patient should sit as far backwards on the table as far as possible so that his back is leaning against the physician’s chest.

3. To treat a dysfunction of the left sternoclavicular and acromioclavicular articulation, which is displaced in the anterior-inferior direction at its lateral aspect, the physician places his left forearm in the patient’s left axillary region and

grasps the patient’s lateral clavicle just medially to the acromioclavicular joint.

4. The physician uses his left forearm that is positioned high up into the patient’s axilla, to pull the patient’s left arm into a lateral direction, creating a traction movement. This is maintained until motion is noted at the sternoclavicular articulation.

5. The physician uses one or more fingers of his right hand on the inferior aspect and the thumb of that hand on the superior aspect of the left sternoclavicular articulation.

6. The physician directs the patient to take a deep breath and then exhale.

7. While maintaining the lateral traction, the physician now moves his right forearm in a slightly inferior direction and then in a lateral and forward direction during the patient’s full exhalation, until he feels motion at the articulation. At the same time, the physician’s hand on the medial aspect of

the clavicle pulls that region superiorly and slightly posteriorly.

8. The patient is instructed to inhale deeply following the exhalation

9. Simultaneously, the physician pulls the lateral aspect of the clavicle superiorly, posteriorly and medially. The medial aspect of the sternoclavicular is simultaneously brought inferiorly, anteriorly, and laterally.

10. If the diagnosis involves Left posteriorly rotated clavicle with the lateral clavicle posterior and superior, the sequencing would be reversed (The physician directs the patient to take a deep breath and hold it. While maintaining the medial traction, the physician now moves his right forearm in a slightly superior direction and then in a medial and posterior direction during the patient’s full inhalation, until motion is noted at the articulation. At the same time, the physician’s hand on the medial aspect of the clavicle pulls that region inferiorly and slightly anteriorly. The patient is instructed to exhale deeply following the inhalation. Simultaneously, the physician pulls the lateral aspect of the clavicle inferiorly, anteriorly and laterally. The medial aspect of the sternoclavicular is simultaneously brought superiorly, posteriorly, and medially).

11. The region is reassessed. There is a possibility that the opposite clavicle is also dysfunctional but not as badly as the initially treated one.


2018

Name(s) of Presenters: Richard A. Feely, DO, FAAO, FCA

Name of College of Osteopathic Medicine Attended: A T Still-KCOM




Name of Presented Technique: Neuro Ocular Release (NOR)

Developer/Source: Richard A. Feely, DO, FAAO, FCA

Description of Technique: Neuro Ocular Release (NOR) is a new Osteopathic

manipulative procedure for the advanced Osteopathic Physicians to treat Somatic

Dysfunction (SD) that uses a stare. The physician-directed NOR stare is a specific

visually/mentally focused ocular nervous system simulation, using several CNS

pathways [The following tracts Ocular, spinothalamic, corticospinal, subconscious

& others] to reset, or erase the Central Nervous System (CNS) memory/learned

behavior associated with that specific SD. It is, in computer parlance, a “warm

boot” to the CNS. This procedure provides a more complete deactivating force of

the complexity of SD when used in conjunction with an Indirect Osteopathic

manipulative technique such as Strain-Counterstrain, Balanced Membranous

Tension (BMT), Balanced Ligamentous Tension (BLT), Functional, Cranial

Osteopathy, etc.

NOR requires a cooperative patient

- A patient with some vision and the ability to focus

- A highly skilled practitioner of Indirect Osteopathic Manipulative

Methods

- Identifiable somatic dysfunction

THE DIFFICULTY is that the physician must be able to perceive changes in tender

points under their fingers and instruct the patient precisely where to stare,

otherwise this technique will not work.

Indications: Acute, Subacute and Chronic SD Patients who can and will follow

directions. NOR even works on patients with cone rod dystrophy(blind) who can

mentally visualize and focus.

Contraindications: Patients unable to follow directions or focus and usual

Contraindications for OMT; Acute Fractures and other acute medical emergencies

Specific Diagnosis: Any SD found on the axial skeleton

Patient Position: depends on the diagnosis, Treatment is Indirect positioning

Physician Position: depends on the diagnosis, Treatment is Indirect positioning


1. The physician positions the patient in a position of maximum ease, using a typical indirect method technique until the discomfort of the tenderpoint is resolved.

2. The SD is further released using the activating force of NOR by having the patient look in a certain direction, usually in the direction of injury.

3. The patient is then asked to focus in a specific direction at a specific point that yields a further structural, fascial, cellular, and an energetic easing of the tenderpoint.

4. A sudden ease is felt over the tenderpoint when the eyes and body are aligned in the summation/energetic force vector that was used in maintaining the SD. Once this is found, a complete release occurs within 2-3 seconds

5. The patient is then asked to close their eyes. 6. The physician slowly repositions the patient’s body back to a

neutral position. 7. Once back into a normal anatomical position; seated or

supine/prone the patient is instructed to open their eyes. 8. This is when the ‘warm boot’ of the central nervous system

occurs. The CNS is reset, balanced and the SD is now an unlearned memory, resulting in no active input to the CNS or PNS for maintaining SD.


2018

Name(s) of Presenters: HARRY D FRIEDMAN, DO, FAAO

Name of College of Osteopathic Medicine Attended: MSU-COM




Name of Presented Technique: SEATED HIP RELEASE

Developer/Source: ERNEST ‘BUD’ BERNHARDI DO FAAO FCA

Description of Technique: (ATTACHMENT WITH PHOTO WILL FOLLOW)

Specific Diagnosis:

Patient Position: seated

Physician Position: sitting facing the patient


The relationship between hips and lumbar spine is a central concern due to the increasing lumbar lordosis in the later months of pregnancy and the associated increase in thoracolumbar tension. Weight bearing mechanics can be assessed and directions of ease applied to help restore functional relations between these important structures.

1. With the patient seated, the operator sits in front of the patient with hands on the patient’s knees.

2. A gentle compressive force is applied directly into the acetabulum through the patient’s legs comparing the relative compliance between the left and right.

3. The operator continues the compressive force into the hip of greatest compliance while distracting the side of greatest tension.

4. The patient is then instructed to sit up straight and actively side bend and rotate slightly in the directions of ease as palpated by the operator through the patient’s legs.

5. Respiration can also be used to accentuate the release, which is immediate.

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2018

Name(s) of Presenters: Stephen I. Goldman, DO, FAAO and Richard L. VanBuskirk, DO, PhD, FAAO

Name of College of Osteopathic Medicine Attended: Goldman-Des Moines; Van Buskirk – West Virginia

Year of Graduation: Goldman-1984; Van Buskirk 1987

Years in Practice: Goldman 31; Van Buskirk 29

Year received FAAO: Goldman 2005; Van Buskirk 1997

Name of Presented Topic: Rethinking Superior and Inferior Sacroiliac Shear a new approach to diagnosis and treatment

Developer/Source: Goldman and Van Buskirk

Description of Technique: Still technique and muscle energy treatment for superior and inferior sidebent innominate

Specific Diagnosis: superior and inferior sidebent innominate

Patient Position: supine

Physician Position: standing at foot or side of the table


Treatment of a superiorly displaced innominate with Still Technique is as follows:

1. With patient in the supine position, the ankle or leg is grasped by the operator with both hands, and the lower extremity is placed in abduction. This will then bring the innominate into its ease position of superior sidebending.

2. Light compression or traction is applied through the lower extremity towards the superior part of the SI joint.

3. Maintaining this compression or traction, the lower extremity is then moved across midline into adduction.

Treatment of an inferiorly displaced innominate with Still Technique is as follows:

1. With patient in the supine position, the leg is grasped by the operator with both hands, and the lower extremity is placed in adduction.

2. Light compression or traction is applied to the lower extremity toward the inferior aspect of the SI joint.

3. Maintaining this compression or traction, the lower extremity is then moved across midline into abduction.

Treatment of a superiorly displaced innominate with muscle energy is as follows:

1. With patient in the supine position, the leg is grasped by the operator with both hands, and the lower extremity is adducted beyond the midline to the palpable barrier.

2. With the physician holding the leg in this position the patient is instructed to push the leg toward abduction for 3-10 seconds.

3. When the patient is told to stop pushing the physician further adducts the leg to the barrier.

4. Repeat two more times.

Treatment of an inferiorly displaced innominate with muscle energy is as follows:

1. With patient in the supine position, the leg is grasped by the operator with both hands, and the lower extremity is abducted away from the midline to the palpable barrier.

2. With the physician holding the leg in this position the patient is instructed to push the leg toward the midline for 3-10 seconds.

3. When the patient is told to stop pushing the physician further abducts the leg to the barrier.

4. Repeat two more times.


2018

Name(s) of Presenters: Laura Griffin, DO, FAAO

Name of College of Osteopathic Medicine Attended: UNECOM




Name of Presented Technique: Cervical HVLA with Traction

Developer/Source: Variations have been shown to me by multiple teachers and mentors but I haven’t seen in it in the literature


Specific Diagnosis: C4 ERS left


Physician Position: Seated at the head


1. The physician places fingers of the left hand on the articular pillars of C4; Thumb on the left and index or middle finger on the right. The patient’s occiput is held by thenar/hypothenar eminences and fourth and fifth fingers

2. The physician’s right hand gently cups the patient’s chin with the forearm alongside the face to provide stability

3. The physician uses translation with left hand to achieve localized sidebending and rotation to the right at C4

4. The physician localizes forces in all 3 planes, again using translation so that neck is in a neutral position overall

5. The physician applies a short vertical/superior tug. The finger applying the right sidebending motion allows for a correction of vertebral motion when the articular facets are slightly distracted

6. Recheck


2018

Name(s) of Presenters: Stefan Hagopian, DO, FAAO

Name of College of Osteopathic Medicine Attended: University of New England College of Osteopathic Medicine




Name of Presented Technique: “Osteopathic Diagnosis & Treatment of Whole Carpal Tunnel”

Developer/Source: Anne L. Wales, DO from William G. Sutherland, DO

Description of Technique: Diagnosis and Treatment of the Carpal Tunnel or Carpal Wrist Strain

Specific Diagnosis: especially in problems of hyperextension at wrist, must look beyond the Transverse Carpal Ligament

Patient Position: Seated, Supine, or Standing

Physician Position: Seated or Standing


UE = Upper Extremity

CTS = Carpal Tunnel Syndrome

TCL = Transverse Carpal Ligament

1. Consideration No. 1 – As in any OSTEOPATHIC DIAGNOSIS & TREATMENT, it is important to perform some amount of

assessment of the WHOLE BEING of your patient, with an initial goal to determine if, when, and how to proceed… most SAFELY and most EFFECTIVELY.

2. Consideration No. 2 – UE problems, especially CTS, often require INITIAL TREATMENT for SOMATIC DYSFUNCTION contributions at cervical, shoulder, elbow & forearm regions.

3. Consideration No. 3 – Assess for GROSS WRIST SOMATIC DYSFUNCTION with ROM testing - passive and/or active.

4. Consideration No. 4 – SOMATIC DYSFUNCTION of the carpal region, whether CTS or otherwise, almost always involves structural and/or functional abnormalities NOT intrinsic to the usually blamed TCL, but rather among the 8 CARPAL BONES and their many small ligaments.

5. DIAGNOSIS OF CARPAL TUNNEL – Assess the CARPAL BONES with the patient’s wrist in neutral posture, palm facing downward. The Operator slides thumbs over dorsum of patient’s carpal bones. If carpal bones have lost their arched structure or their springing function, they may appear to have fallen into the carpal tunnel. This can be indicated by a dorsal carpal bone depression, analogous to a dropped transverse arch in the foot. While assessing from the dorsal aspect it may appear as a structural “drop-off” or a functional sag when sliding the physician’s thumbs over the dorsum of patient’s wrist from distal radius & ulna onto the dorsal surface of carpal bones.

6. Treatment Step 1 – The Hand of patient is held up in front of their head or neck, with PALM FACING PHYSICIAN.

7. Treatment Step 2 – The Physician firmly CLASPS hid or her own interlaced FINGERS behind DORSUM of patient’s wrist at the carpal bones.

8. Treatment Step 3 – The Physician CROSSES his or her THUMBS across the ventral surface of the patient’s PALM, at level of carpal bones, which are found at the most proximal portion of thenar and hypothenar eminences, in preparation to stretch the TCL.

9. Treatment Step 4 – The physician MAINTAIN’S the patient’s dorsal CARPAL CONVEXITY by clasping his or her fingers firmly AROUND the dorsum of patient’s wrist, careful not to compress the apex of dorsal transverse arch. It also helps to maintain patient’s WRIST in slight FLEXION or at least neutral position, while the physician then further crosses his or her own thumbs to STRETCH THE TCL, pressing laterally upon thenar and hypothenar eminences. This can be a firm grasp and a forceful stretch.

10. Treatment Step 5 – The patient is then directed to SPREAD ALL 5 FINGERS into full abduction and extension, which should exert a slight widening force upon the inside of patient’s Carpal Tunnel.

11. Treatment Step 6 – The patient is then directed to MAKE A FIST by tightly flexing all 5 fingers, which should dramatically move all tendons within their Carpal Tunnel, while the physician maintains the dorsal carpal convexity with clasped fingers and stretches the TCL with the crossed thumbs. The Physician also maintains the patient’s wrist in neutral, resisting any tendency toward wrist extension as the patient attempts to close their fingers into a fist.

12. Treatment Step 7 – The patient is then directed to open the fist and RELAX their fingers and hand.

13. Treatment Step 8 – The patient is then directed to FLEX WRIST and repeat the “finger-spread” & “make-a-fist” actions

as in Steps 5 & 6 above, while the physician reapplies the same hold as in the above Treatment Steps 1-4. This stretches the TCL from inside of tunnel by the pull of patient’s flexor tendons beneath the TCL (like an archer pulling with fingers upon the string of their bow).

14. Treatment Step 9 – The patient is directed to open their fist and RELAX.

15. RECHECK as in “DIAGNOSIS OF CARPAL TUNNEL” above.


2018

Name(s) of Presenters: R. Paul Lee, DO, FAAO, FCA

Name of College of Osteopathic Medicine Attended: UHS-COM (Kansas City)




Name of Presented Technique: Intraosseous Strain of the Pelvis

Developer/Source: R. Paul Lee, DO, FAAO, FCA

Description of Technique: Restore Harmony to 3 Parts of the Pelvis

Specific Diagnosis: Feel PRM Simultaneously at 3 Contacts

Patient Position: Prone or Supine (Supine preferred)

Physician Position: Seated beside the pelvic region of the patient


PART I – Restore harmony to the 3 parts of the Pelvis 1. Contact ischial tuberosity with fingertips of the hand that is

closer to the patient’s feet 2. Contact PSIS with the fingers of the other hand 3. Alternatively, contact the ASIS and pubic tubercle

simultaneously with the second hand 4. Feel the primary respiration with both hands 5. If poor synchrony between contacts with both hands, there is

evidence of strain

6. Direct one or more parts of the pelvis into the direction of ease in which it is strained

7. Find the balance point for deviation and wait 8. Once the breathing of the PRM is synchronous throughout

the 3 parts of the pelvic bone, wait until synchrony is appreciated beyond into the spine, head and extremities

9. Wait for the still point 10. With resumption of easy PRM, the treatment is finished 11. The process can be repeated for the opposite side pelvic

region

PART II - Balance the femoral head in the acetabulum, the sacrum with the pelvis and the L5 with the sacrum

12. Place the palm on the greater trochanter and project into the head of the femur

13. Direct the head of the femur into its direction of ease 14. Wait for a sense of release 15. With the hand that is closer to the patient’s feet grasp the

sacrum between the sacrum and the table surface and with the other hand grasp the pelvis on the side to be treated at the ASIS and the iliac crest.

16. Bring the two structures into position of relative ease relative to each other

17. Wait for a sense of release 18. Maintaining the hand that was on the sacrum, place the

other hand beneath the patient at the level of the L5 vertebra 19. Place the index and middle fingers on the transverse process

on the opposite side, the thumb beneath the transverse process on the same side and support the spinous process with the palm

20. Bring the L5 into all planes of ease and the sacrum into ease relative to the L5

21. Wait for a sense of release 22. Reassess


2018

Name(s) of Presenters: Doris Newman, DO, FAAO

Name of College of Osteopathic Medicine Attended: UNE COM


Years in Practice: 16 years


Name of Presented Technique: OMT of the SBS-OA-AA utilizing BMT and BLT: a combination technique to improve Axis motion Developer/Source: Dr. Newman, clinical experience


Specific Diagnosis: Upper Cervical SD, specifically targeting C2 rotation


Physician Position: Seated, head of table


1. The Patient is supine, and the physician is seated at head of table.

2. (Figure 1 for steps 3-9)

3. The Physician’s hands in the anteroposterior Anterior-Posterior handhold.

4. The Top/anterior hand spans the patient’s forehead with the middle finger and thumb on opposite sides making gentle contact with the greater wings of the sphenoid on either side.

5. The Bottom/posterior hand cradling the patient’s occiput on the thenar and the hypothenar eminences and the index finger and thumb on opposite sides of the transverse processes of C2. Phase 1: Balance Membranous Technique of the SBS:

6. While focusing on the purposeful action between the anterior and posterior palms, use the appropriate forces necessary to “meet the forces” found at the patient’s spheno-basilar-synchondrosis (SBS). (compression, torsion, side-bending).

7. With the palms of both hands, meet those forces until a balance point of the SBS and associated tissues and membrane is felt. The forces in the tissues may be profound and “meeting the forces” may take quite a bit of compressive force from the physician.

8. The focus of phase 1 of the treatment is the SBS but the physician should continue to assess all the corresponding tissues. The balance point will not be complete but should be improved during phase 1. (Figures 2 and 3 for steps 10 – 17) Phase 2: Balanced Ligamentous Tension Technique of the upper cervical spine: (Figures 2 and 3 for steps 9-14

9. While maintaining the treatment in phase 1 at the SBS, with the inferior hand, the physician moves her attention to the Axis.

10. Manipulating the subtle motions of the C2/axis into all planes of motion (flexion/extension, rotation, subtle sidebending, compression/distraction, etc.) until a balance point is felt in the tissues of the suboccipital region.

11. This will take several changes in position as the tissues relax and a new balance point is obtained. Phase 3: Combination treatment of the SBS to C2:

12. The physician should continue each phase of the phases 1 and 2 of the treatment in such a manner that each new balance point at the SBS improves the balance point at the C2 and vice versa.

13. At the end of the treatment, the atlas (C1) may appear to “float” between the occiput and the axis.

14. The target segment, C2/axis, should be reassessed for improvement.


2018

Name(s) of Presenters: Karen T Snider DO FAAO FNAOME

Name of College of Osteopathic Medicine Attended:

West Virginia School of Osteopathic Medicine




Name of Presented Technique: Joint Mobilization Muscle Energy for the Cervical Spine using Sagittal Plane Activating forces.

Developer/Source: Technique concepts were likely developed by AT Still, but the first published joint mobilization muscle energy technique was described by Francis J. Feidler, D. 0. in his 1906 publication of the Household Osteopath. Muscle energy as a discrete set of techniques were described and published by Fred Mitchell Sr and Jr. The presented cervical technique was modified from the original published versions by K Snider.

Description of Technique: Muscle Energy technique using an anterior or posterior activating force to gap the articular structures of the cervical spine. Technique works very well for segmental cervical dysfunction in the presence of uncinate joint arthritis with degenerative disc disease.

Specific Diagnosis: Extended or Flexed triplanar or uniplanar cervical dysfunction


Physician Position: Seated or standing


1. Screen the cervical spine and diagnosis the worst segment. 2. With one hand cradling the occiput and the other hand on

the dysfunction segment, position the segment at the direct motion barrier. For example if C3 is flexed, sidebent right, and rotated right, then position the segment extended, sidebent left, and rotated left.

3. If the dysfunctional segment is flexed, then instruct the patient to push their head posteriorly toward the direct motion restriction barrier for 3-5 seconds. Resist this posterior motion with your hand on the occiput.

4. If the dysfunctional segment is extended, instruct the patient to swallow or engage them in conversation to create a localized flexion force at the dysfunctional segment.

**The activating force is in the direction of the direct motion restriction barrier and should gap the affected articular structure. A joint articulation may occur upon patient relaxation as the joint reseats itself.

5. After the patient relaxes completely for 1-2 seconds, localize to the new restrictive barrier.

6. Repeat 3-5 times and recheck.


2018

Name(s) of Presenters: Edward G. Stiles, DO, FAAO

Name of College of Osteopathic Medicine Attended: Kirksville College of Osteopathy and Surgery ( KCOM )




Name of Presented Technique: T12 FRSL principles-based technique

Developer/Source: Paul Kimberly, DO, FAAO and Edward G. Stiles, DO, FAAO


Specific Diagnosis: T12 FRSL


Physician Position: standing posterior and to the side of the patient


Anatomical reasons why FLEXED T12 are difficult to treat

• Upper facet pair are coronal facing: can flex, extend, side bend and rotate.

• Lower facet pair are sagittal facing: can flex, extend but sidebending and rotation are very limited.

• Therefore, confusing afferent input from the upper and lower facet pairs when FRS dysfunctional present. The CNS has two options when somatic dysfunction in introduced, either relax the paravertebral muscles or

“lock it down with paravertebral muscles contraction.” Therefore, a complex segmental dysfunction emerges.

• In addition, when T12 is flexed, this can stimulate the innervation to the psoas and result in increased psoas tone. This also decreases the lumbar lordosis and further makes it difficult to place T12 in extension.

Long form description: MET traditional

Diagnosis: T12 FRSL

Treatment positioning: with MET direct, (ie, ERSR )

• Patient is sitting erect on treatment table • The patient crosses their arms, so hands are on the lateral aspect of the

proximal arms • The physician is standing posterior and to the right of the patient • The physician reaches around patient and grasps the patient’s elbows • The operator palpates over T12 with his/her left hand • The operator uses his/her right arm to now position the patient into

extension Extension Right side bending Right rotation Therefore, up against the restrictive barrier in 3 planes

• The operator establishes an “unyielding counterforce” with his/her right arm

• The patient makes a gentle muscle effort of side bending left and rotation left and hold for 3-5 seconds.

• Repeat 3 times • When retested, frequently a correction has not been attained. This

frequently let to frustration due to the poor outcome.

Long form description: Stiles’ MET modification

Diagnosis: T12 FRSL

Treatment positioning: with MET direct, (ie, ERSR)

• An alternative approach

• Patient is sitting erect • Clinician stands behind and to the right of the patient. • Clinicians right hand holds the patient’s right shoulder and • Physician Introduces, while palpating with his/her left hand at T12,

Extension Side bending right Rotation right

• Patient makes a bending left and rotation left MET against an “unyielding counterforce”.

Hold MET effort x 3-5 seconds Repeat 3 times

• Recheck and frequently no changes has been made.

Stiles’ Short form for correcting T12 FRSL

I discussed my frustration when I treated T12 FRSL dysfunctions with Paul Kimberly.

Kimberly discussed the unique facet anatomy presented above.

Then Kimberly stated, “know the principles and then you can get them to work for you then you don’t have to work as hard.”

Kimberly then asked Stiles a profound question,

. “Did you ever consider using Type I mechanics to reverse the rotation of a Type II dysfunction?”

. “Then use Type II mechanics to complete the treatment.”

These clinical principles are applied in the following manner.

Diagnosis: T12 FRSL short form based on principles

( I will demonstrate as talk it through )

Treatment: treat in 2 steps

Step 1: using Type I mechanics to reverse the T12 left rotation • Then use Type II mechanics to position ERSR • Patient is sitting erect on the table

• Clinician stands posterior and to the right of the patient • Clinician palpates at T12 with his/her left thumb and 1st finger at the T12

level. • Position the patient so T12 is in neutral compartment. • Then the clinician introduces side bending left by using the left hand to

translate T12 to the right as the right hand on right shoulder simultaneously introduces left side bending. If the patient is in neutral, T12 will start to rotate toward the right. (activated Type I mechanics). If it rotates to the left, you know the patient is not in neutral and positioning needs to be fine tined.

• The patient then makes a MET effort of side bending toward the right against the operator’s unyielding counter force on the lateral aspect of the right shoulder. Repeat 2-3 times.

• Then have the patient actively translate the abdomen forward while simultaneously bringing their shoulders and head posterior. As the patient moves from the neutral compartment into the extension (Type II compartment), the patient’s body automatically side bends right. It has no other option since T12 is now in the extension compartment and T12 is rotated right.

• The patient then makes 2-3 MET efforts of side bending and rotation toward left against the unyielding counterforce on the right shoulder to complete the treatment.

• Therefore, the T12 segment has ended up ERSR . . . what T12 could not previously do.

• Retest to confirm treatment effectiveness. • Usually there is a dramatic improvement in the mechanics and clinical

picture.


2018

Name(s) of Presenters: Sara E. Sutton, D. O., FAAO

Name of College of Osteopathic Medicine Attended: Still College of Osteopathy & Surgery, now Des Moines University


Years in Practice: 61 years


Name of Presented Technique:

Developer/Source:

Description of Technique: DIRECT ACTION with RESPIRATORY COOPERATION

(DARC)

Specific Diagnosis: Dependent on Region

Patient Position: Dependent on Region

Physician Position: Dependent on Region


T5 TO L5

EXAMPLE L5 FrSr and Left Flexed Sacrum

Pt = patient Op= operator (right eye dominant) Requirement: SHORT FINGERNAILS!! SS = sacral sulcus L= lumbar

PSIS = posterior superior iliac spine L5 FRrSr= lumbar vertebra 5 is flexed, rotated right and side-bent right

DIAGNOSIS OF FLEXED SACRUM

1. Pt lies prone, far to the left edge of table (for a right eye dominant Op) with heels slightly rolled out.

2. Op stands to the left side of the table. 3. Op locates ILA & determines if one side is more posterior and caudad.

This is easiest done by having the thumbnails facing each other as you gently slide the thumbs anterior until you feel the sharp ridge of the ILA. Note which side is caudad, then move the pads of the thumbs up over the posterior surface of the ILA to determine which side is posterior. Posterior & Inferior usually "go together".

4. SS is evaluated for depth (left deep for this diagnosis).

DIAGNOSIS OF LUMBAR FLEXED DYSFUNCTIONS

1. Pt is asked to get up on elbows under shoulders to extend spine, making sure elbows are level with each other.

2. Determining the side of the rotation of L5: the side of the rotation will be determined first by the position of the posterior transverse process, and then by motion testing.

3. Op places pads of thumbs on posterior surfaces of PSIS and moves the tips of the thumbs at 45 degrees medial & cephalad to be over the transverse processes of L5, slightly lateral to the side of the spinous process of L5. The Op will see if one transverse process is more posterior than the other.

4. To perform motion testing, the Op slightly pushes forward on the right to takes out the rotation slack, then does a short anterior springing motion; then does the same on the left, to determine if one side will not rotate as far. (With this diagnosis, the right side will be restricted in anterior motion.)

5. In practice each segment from L5 to about T5 may be examined in this way, with a pen mark on the skin over the side toward which the segment is rotated. T 1-4 can more easily be diagnosed and treated in a seated position.

TREATMENT OF L5 FrSr

Fred Mitchell, D. O. Sr. stressed that the pubic dysfunction and ALL lumbar dysfunctions should be treated before treating any sacral dysfunction. Recheck the sacral diagnosis after treating all the lumbars, as it may change or disappear after lumbars are treated. From experience I learned that while the patient is in the prone position with the elbows on the table and palms of hands under the chin (the "Sphinx" position) moving the right elbow forward (with this diagnosis) in increments up to an inch will help de-rotate the segment because it rotates the Pt's torso to the left. If that is not adequate to de-rotate the vertebra as much as needed, then it may be necessary to move the left elbow slightly caudad.

1. Pt lies in the "sphynx" position close to the left edge of table with heels slightly rolled out (to internally rotate the thighs).

2. Op stands to the left side of the table and places thumbs over L5 transverse processes and checks for restricted rotation, one side at a time. The right side will be restricted in this diagnosis.

3. The Pt is asked to move the right elbow forward about 1". 4. Op rechecks rotation testing and may need to have Pt repeat small

increments of forward elbow motion until rotation is equal right and left.

5. With the left hand on the lateral aspect of the torso at the level of L5, the Op translates the L5 vertebra slightly to the right (left side-bending) and asks the Pt to inhale, then exhale. At the same time of the exhalation AND the side-bending the Op puts downward pressure on the R transverse process (L rotation).

6. Op rechecks position and motion of the transverse processes.

TREATMENT OF LEFT FLEXED SACRUM

1. Pt lies prone, far to the left edge of the table. 2. Op stands to the left of side of the table.

3. Op places fingertips along the left sacral sulcus (medial to the PSIS and lateral to the sacral spine).

4. Op bends the patient's left knee to 90 degrees. Then the Op uses his anterior forearm on the medial ankle to press the lateral ankle to his chest wall to lift (or extend) the thigh slightly. The fingers of left hand of the Op are palpating the tension of the ligaments at the sacral sulcus. Then the Op will abduct the left thigh to find a balanced ligamentous tension. (If the Op abducts or adducts too far, then the ligaments tense up.) Then lets the leg rest on the table.

5. Op lets the Pt's left lower leg fall to the left (internal rotation of the thigh) allowing foot to rest against the Op's lateral rib cage.

6. Op places the left finger tips along the Pt's left sacral sulcus. 7. Op's R hypo-thenar eminence rests on caudad (NOT on the posterior)

surface of L ILA. 8. Op checks the angle of cephalad motion which best takes the sacral

base superior and posterior. Different angles of motion can be induced by raising or lowering the elbow while pushing on the ILA.

1. The angle of cephalad motion induced by pressure on the ILA is not the same in every patient because the shape of the sacroiliac joint is different in every patient, even in the same sacrum.

2. Therefore, the angle needs to be checked carefully while monitoring the movement of the sacral base during treatment.

9. Op asks the patient to take a deep breath and hold it. While the Pt is inhaling the ILA is being guided cephalad. This can be repeated up to 3 times if needed.

10. Op then brings the left thigh and leg to symmetry with the right. 11. Op then will recheck the sacral sulci and ILAs.

SEATED CERVICAL SPINE DIAGNOSIS

OCCIPITO-ATLANTAL JOINT: (OA)

The rotation and sidebending of the OA are always opposite. If the OA is rotated left it will be sidebent to the right.

Pt = patient Op= operator (right eye dominant) Requirement: SHORT FINGERNAILS!! OA = occipito atlantal joint OA ESrRl=occipito atlantal joint extended, sidebent, right and rotated left C= Cervical C5 FRrSr= cervical vertebra 5 is flexed, rotated right and side-bent right

DIAGNOSIS OF OA

1. Op stands to the side of the seated patient facing them. 2. Op has one hand with the radial aspects of the index finger and thumb

under the occiput. The hypothenar eminence may rest on the upper back.

3. The Op's other hand is on the forehead 4. Op then translates the occiput on the atlas to the right and to the left

when the joint is flexed. This is repeated when the joint is extended. 5. Interpretation:

a. If the occiput is translated right, then it is sidebent to the left and therefore rotated to the right.

b. If a restriction is found in extension, then the somatic dysfunction is called flexed.

TREATMENT OF THE OA JOINT

Muscle Energy set up for Extended somatic dysfunction:

1. Op’s two hands flex the head and upper neck until a motion is felt at

the OA joint. 2. Then the Op introduces sidebending & rotation opposite the somatic

dysfunction. 3. Op asks the patient to VERY GENTLY TURN the head to one side (either

right or left depending on the diagnosis) for 3 to 5 seconds. The physician says also that the push should be so gentle that the head should not move while the patient is pushing. It is an isometric contraction.

4. Op maintains the level of flexion already attained and induces slightly more sidebending and rotation to the next barrier.

5. Repeat above two steps 1 or 2 times. 6. Recheck vertebrae in flexion and extension.

Muscle Energy set up for Flexed somatic dysfunction:

1. Op’s two hands extends the head and upper neck until a motion is felt

at the OA joint. 2. Op introduces sidebending & rotation opposite the somatic

dysfunction. 3. Op asks the patient to VERY GENTLY TURN the head to one side (either

right or left depending on the diagnosis) for 3 to 5 seconds. The physician says also that the push should be so gentle that the head should not move while the patient is pushing. It is an isometric contraction.

4. Op maintains the level of extension already attained and induces slightly more sidebending and rotation to the next barrier.

5. Repeat above two steps 1 or 2 times. 6. Recheck vertebrae in flexion and extension.

DIAGNOSIS OF ATLANTO-AXIAL (A-A) DYSFUNCTION

1. Pt is seated with Op standing in front of Pt. 2. Op hyperflexes the C spine to isolate the main motion to A-A. 3. While maintaining the cervical flexion the Op gently tests rotation

right, then left and decides which side rotates least. a. The Op may mark with a pen on the Pt's clavicle the point of

maximum rotation to each side. That way the difference in rotation can be visually noted more clearly.

4. The somatic dysfunction of the AA is named for the side that rotates the furthest; example restricted right, therefore diagnosis is rotated left.

TREATMENT OF A-A rotated left

1. Pt is seated with the neck hyperflexed

2. Op places right hand along the Pt's left cheek and induces rotation to the right to engage the restricted motion barrier.

3. Op then asks the pt. to gently rotate the neck to the left for 2-3 seconds as the Op offers gentle resistance. The head should NOT move during the contraction.

4. Pt. relaxes for 2-3 seconds while Op maintains position. 5. Op then rotates the head to the next rotation barrier. 6. Op then repeats the isometric contraction another time or two. 7. Recheck findings.

SEATED DIAGNOSIS OF CERVICAL SPINE In practice each segment from C2 to C7 is evaluated in flexion and extension. If a somatic dysfunction is found, it is treated then and there. However, for the sake of instruction we will explain the diagnosis and treatment of extended and flexed dysfunction separately.

SEATED DIAGNOSIS OF EXTENDED LOWER CERVICALS (C2-6)

1. Op stands and faces the side of the Pt. 2. The pads of the thumb tip and middle finger contact the articular

pillars (by sliding forward about one finger breath lateral to the spinous process).

3. The other hand cradles the forehead with the thumb and out-stretched middle finger.

4. Op flexes the neck until the facets open at the level being tested. 5. The thumb and finger on the facets remain mainly passive as the Op

introduces slight coupled side-bending and rotation in each direction. Motion is induced mainly by the hand on the forehead. The fingers on the facet joints may very slightly intensify the translation. If there is restricted left sidebending, the rotation to the same side is assumed to be restricted. The diagnosis would be ERrSr.

Cervicals 3 to 6 are in turn examined by having the Op move palpating fingers caudad, examining each level by adding small degrees of C flexion before checking translation. I usually treat each segment after diagnosing.

SEATED TREATMENT OF C2-6 EXTENDED SOMATIC DYSFUNCTIONS

Muscle Energy set up for Extended somatic dysfunction

1. Op’s hand on the forehead FLEXES the neck until a motion is felt at the specific cervical level.

2. Op introduces sidebending & rotation opposite the somatic dysfunction diagnosis.

3. Op asks the patient to VERY GENTLY TIP the forehead head to the diagnosed sidebent side for 3 seconds without moving the head. This is an isometric contraction.

4. While maintaining the flexion already attained, the Op induces more sidebending, and rotation to the next barrier.

5. Repeat above two steps 1-2 times. 6. Recheck vertebrae in flexion and extension.

SEATED DIAGNOSIS OF FLEXED LOWER CERVICALS (C2-6)

1. Op stands and faces the side of the pt. 2. The pads of the thumb tip and middle finger contact the articular

pillars (by sliding forward about one finger breath lateral to the spinous process).

3. The other hand cradles the forehead with the thumb and out-stretched middle finger.

4. Op extends the neck until the facets close at the level being tested. 5. The thumb and finger on the facets remain mainly passive as the Op

introduces slight coupled side-bending and rotation in each direction. Motion is induced mainly by the hand on the forehead. The fingers on the facet joints may very slightly intensify the translation. If there is

restricted left sidebending, the rotation to the same side is assumed to be restricted. The diagnosis would be FRrSr.

Cervicals 3 to 6 are in turn examined by having the Op move palpating fingers caudad, examining each level by adding small degrees of C extension before checking translation. I usually treat each segment after diagnosing.

SEATED TREATMENT OF C2-6 FLEXED SOMATIC DYSFUNCTIONS Muscle Energy set up for Flexed somatic dysfunction

1. Op’s hand on the forehead EXTENDS the neck until a motion is felt at

the specific cervical level. 2. Op introduces sidebending & rotation opposite the somatic

dysfunction diagnosis. 3. Op asks the patient to VERY GENTLY TIP the forehead head to the

diagnosed sidebent side for 3 seconds without moving the head. This is an isometric contraction.

4. While maintaining the extension already attained, the Op induces more sidebending, and rotation to the next barrier.

5. Repeat above two steps 1-2 times. 6. Recheck vertebrae in flexion and extension.

DIAGNOSIS OF C7 ERlSl

1. Pt is seated, and Op stands behind the Pt. 2. Starting at C2 the Op places sides of index fingers at the tips of the

transverse processes, and with light pressure slides them caudad until they come in contact with the top of C7, which has the longest trans-verse processes. In this illustration the right side will be more cephalad; so C7 is sidebent left.

3. Op asks the patient to flex the neck and determines if the level of the transverse processes becomes more or less symmetric. a. If the transverse processes become more asymmetric in flexion,

then the somatic dysfunction is extended.

TREATMENT OF C7 ERlSl

1. Op places right index finger on top of C7 transverse process. 2. Op places left forearm along left side of Pt's face. 3. With the right thumb palpating the spinous process of C7, the Op

flexes the Pt's neck until a gapping motion is felt at the C7-T1 interspinous ligament.

4. Op induces a coupled motion of rotation and sidebending of the head and neck to the right until the Op feels the caudad motion of the right transverse process.

5. Pt is asked to gently tip their head to the left against the Op's left arm, as Op offers a gentle isometric resistance.

6. Pt is asked to relax a few seconds, and then the Op takes up right rotation to engage the barrier.

7. Repeat one or two times. 8. Recheck the same way the diagnosis was obtained.

This diagnosis and treatment was taught to me by Paul Kimberly, D. O., FAAO, my first mentor. Sara E. Sutton, D. O., FAAO

evening with the faaos - academy of osteopathy

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