INTENSIVE UPDATE AUGUST 24 - 26, 2018 & BOARD REVIEW Loews Chicago O’Hare Hotel Rosemont, IL INNOVATIVE • COMPREHENSIVE • HANDS-ON Breakout Session 2: OMT for the Lumbar, Spine and Sacrum Harald Lausen, DO, FACOFP Elias Ptak, DO The American College of Osteopathic Family Physicians is accredited by the American Osteopathic Association Council to sponsor continuing medical education for osteopathic physicians. The American College of Osteopathic Family Physicians designates the lectures and workshops for Category 1-A credits on an hour-for-hour basis, pending approval by the AOA CCME, ACOFP is not responsible for the content. 8/13/2018 Intensive Board Review: OMT Breakout Session Rosemont, IL August 2018 Lumbar, Innominate, Sacrum Diagnosis and Treatment Review Elias J. Ptak, D.O. Harald Lausen, D.O., M.A. Associate Professor in Professor of Family & Osteopathic Manipulative Community Medicine Medicine Southern Illinois Touro University-Nevada University Medicine College of Osteopathic Medicine Lumbar Anatomy and Landmarks L4 is approximately at the level of the iliac You can find this landmark With this approach you crest with the patient standing, can then contact the seated or prone transverse processes 1 8/13/2018 Lumbar Anatomy and Landmarks • By identifying L4’s spinous process you T12 can then effectively L1 count up to find the L2 specific segment of L3 interest as well as the L4 thoracolumbar L5 junction/lower thoracic segments Lumbar Somatic Dysfunction Diagnosis L R In this image the RIGHT L4 transverse In this image the LEFT L4 transverse process is posterior, indicating L4 to be process is posterior, indicating L4 to be rotated RIGHT rotated LEFT 2 8/13/2018 “Fryette” Mechanics • Type I • Type II Motion/Somatic Motion/Somatic Dysfunction (Non-neutral) Dysfunction (Neutral) • Non-neutral somatic dysfunctions of the thoracic • Neutral somatic or lumbar spine (either dysfunctions of the flexed or extended) occur at thoracic or lumbar a single vertebral unit: spine: sidebending sidebending and rotation and rotation in a occur in the same directions group occur in opposite directions. • When treating group dysfunctions the APEX of the group is the focus of the treatment Something to consider… • “If your treatment involves an active correction, thrust, or HVLA, you are to set the patient into the proper position only and verbalize the mechanism and direction of your correction. You are not to complete the active correction. Performing an active correction, thrust or HVLA is grounds for immediate failure of the entire exam.” -AOBFP website 3 8/13/2018 Muscle Energy: Lumbar FRS- L4 FRLSL • The patient is seated and you stand or sit behind the patient. • With the left hand, monitor the interspinous region between L4 and L5 and the transverse processes of L4. • Bring the patient’s upper trunk into extension, right side bending, and right rotation to the L4 segment. Muscle Energy: Lumbar FRS- L4 FRLSL cont. • The patient performs an isometric contraction attempting to side bend to the left against your counterforce for 3-5 seconds. • The patient then relaxes and slack is “taken-up” until the next restrictive barriers are engaged. • This contraction, relaxation, and barrier re- engagement cycle is repeated up to 3 times until adequate improvement in motion is obtained. 4 8/13/2018 Lumbar Soft Tissue: Prone Traction • Stand at the side of your prone patient. • One hand is placed over the sacrum with the fingers directed caudal, the other hand is placed over the lumbosacral junction with fingers directed cephalad • Exert a mild anterior force (inhibitory pressure) with each hand in opposing directions. (superior and inferior) This force can be sustained or intermittent to accomplish decompression of LS junction or paraspinal muscle softening • You may place the cephalad hand on one side of the spinous processes, with similar action and can capitalize on the respiratory cycle to aid this process. Lumbar Soft Tissue: Thoracic (and/or Lumbar) Prone or Lateral Recumbent Pressure • Stand at the side of the prone patient • On the opposite side of the area to be treated, place the thumb and thenar eminence of each hand on the paravertebral muscles lateral to the spinous processes. • Exert an anterolateral pressure on the soft tissues, directed laterally away from the spine, bowstringing the musculature. • Maintain the pressure as a sustained inhibitory pressure, or use it in an intermittent fashion to soften hypertonic musculature. • Repeat as necessary at various levels. • This can also be conducted on the lateral recumbent patient. Modified Lumbar Soft Tissue Lateral Recumbent 5 8/13/2018 Lumbar Soft Tissue: Prone Pressure with Counter Leverage • Stand at the side of your prone patient. • Contact the lumbar paravertebral muscles on the contralateral side of the spine with the heel of your cephalad hand. • Contact the ASIS with your caudal hand, inducing a posterior force. • Apply an anterior and lateral force, to stretch the lumbar paravertebral tissues bowstringing the musculature • Allow the ASIS to return to the table, while maintaining and gently increasing the resistance of your cephalad hand further stretching the paravertebral muscles. • Repeat as necessary at additional levels to reduce hypertonic lumbar musculature. Sympathetic Viscerosomatic Reflexes • T1-5 Heart • T10-L2 Genitourinary Tract • T2-7 Lungs • T10-L1 Kidneys and upper ureter • L1-2 Lower ureter • T2-9 Upper GI Tract • T11-L2 Bladder • T2-8 Esophagus • T10-11 Testes/Ovaries • T5-9 Stomach and Duodenum • T10-L2 Uterus & Cervix • T11-L2 Penis/anterior vaginal wall & • T8-L2 Mid and Lower GI Clitoris Tract • L1-2 Prostate • T9-11 Small Intestine through ascending colon • T8-L2 Transverse colon Parasympathetic viscerosomatic reflexes: through rectum • Sacral plexus (S2-4) • T10-L2 Vasomotor to • Lower ureter and bladder • Uterus, prostate and genitalia Lower Extremities • Distal 1/3 of transverse colon, descending colon, sigmoid colon, and rectum 6 8/13/2018 Lumbar High Velocity, Low Amplitude: Initial Positioning • Regardless of the diagnosis; Extended, Flexed or Neutral…the patient is positioned so that they are lying on the side that they are side-bent toward. Examples: • L1 ERSL : the patient is lying on the left side • L3 FRSR : the patient is lying on the right side • L1-3 NSLRR : the patient is lying on the left side L2-FRS left 1. The patient lies on the LEFT side • THIS IS THE SAME SIDE THE PATIENT IS SIDEBENT TOWARD 2. The shoulders and pelvis are perpendicular to the table. 3. The physician monitors the interspinous space between L2 and L3 4. The physician induces extension at this interspinous space from below using the lower extremities 5. The monitoring hands are switched and the physician induces extension at this interspinous space from above using the shoulders/torso. 7 8/13/2018 L2-FRS left cont. 6. The patient is asked to straighten the bottom (left) leg and the foot of the top leg (right) is placed in the popliteal fossa. 7. The patient’s left arm is used to pull the left shoulder anteriorly inducing RIGHT rotation of the Rotation torso down to the dysfunctional segment 8. The physician then grasps the elbow of the left upper extremity and pulls cephalad to induce right side bending from above the apex of the dysfunction. At this point the patient is positioned into the extension, right rotation, and right Side bending side bending restrictions of L2 on L3. L2-FRS left cont. Now, with the patients right foot in the left popliteal fossa and positioned to engage the restrictions in extension, right rotation, and right side bending the physician can provide a High Velocity-Low Amplitude thrust to correct the restrictions. 8. The physician places his /her right forearm on the anterior aspect of the patient’s right chest/shoulder . 9. The physician places his/her left forearm on the inferior aspect of the patients right iliac crest inducing an anterior and superior movement localized to the dysfunctional segment. 10. A high velocity low amplitude force is induced with the left forearm in an anterior/superior direction while maintaining a static counterforce on the right shoulder/chest. 8 8/13/2018 L2 ERS left 1. The patient lies on the LEFT side • THIS IS THE SAME SIDE THE PATIENT IS SIDEBENT TOWARD 2. The shoulders and pelvis are perpendicular to the table. 3. The physician monitors the You can use a interspinous space between L2 pillow under the patient’s head to and L3 carry him further 4. The physician induces flexion at into flexion this interspinous space from below using the lower extremities 5. The monitoring hands are switched and the physician induces flexion at this 6. The patient is asked to straighten the interspinous space from above bottom (left) leg and the foot of the top using the shoulders/torso. leg (right) is placed in the popliteal fossa. L2 ERS left cont. 7. The patient’s left arm is used to pull the left shoulder anteriorly inducing RIGHT rotation of the torso down to the dysfunctional segment; L2 on L3 Rotation 9 8/13/2018 L2 ERS left cont. 8. The physician then grasps the elbow of the left upper extremity and pulls cephalad to induce right side bending from above the apex of the dysfunction. At this point the patient is positioned into the flexion, right rotation, and right side bending restrictions of L2 on L3. Side bending L2 ERS left cont. Now, with the patients right foot in the left popliteal fossa and positioned to engage the restrictions in flexion, right rotation, and right side bending the physician can provide a High Velocity-Low Amplitude thrust to correct the restrictions. 9. The physician places his /her right forearm on the anterior aspect of the patient’s right chest/shoulder. 10. The physician places his/her left forearm on the inferior aspect of the patients right iliac crest inducing an anterior and superior movement localized to the dysfunctional segment.