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Objectives:
a. List and describe the common indirect osteopathic techniques.
b. Give examples of indirect techniques and explain their activating forces.
c. Define and describe the appropriate application of indirect techniques to the lumbar spine.
d. Review the indications/contraindications for indirect treatment.
e. Discuss the barrier concept and how it applies to indirect osteopathic techniques.
f. Introduce and describe kinetic chain imbalance.
g. Describe muscle imbalance patterns in hip and pelvis, specifically “dead butt”, piriformis and psoas
syndrome, and their treatments
h. Demonstrate FPR techniques for Piriformis, Lumbar and Sacrum
Requirements
- In order to treat with indirect techniques (or direct for that matter) you must have a firm understanding of the
where the dysfunctional facet is located that is causing your somatic dysfunction and the findings c/w the
diagnosis.
- (review dysfunctional facets briefly)
Terminology
Why is this important?
- Each school not only teaches things differently, they describe things differently.
- Board questions are written by all the faculty of the various schools
Review: L3 N Sright Rleft: Review: L3 ESRright:
Neurophysiology:
“immobility of a lesioned segment was initiated or maintained by an
increased gain in gamma motor neuron activity of that segment” - Korr.
“an inappropriately high gain-set of the muscle spindle results in changes
characteristic of somatic dysfunction” - Bailey.
The primary neurophysiologic mechanism affected by FPR is thought to
be the relationship between Iα-afferent and γ-efferent activity
If the dysfunctional segment is positioned appropriately, the fibers may
return to normal length, which decreases tension in the fibers
This reduced tension in the area of the muscle spindle eliminates the
afferent excitatory impulses
This “quiets” the gamma motor gain, reducing the stretch stimuli, and eliminates the reflex activation of the
α-motor neuron
This allows the tension and hypertonicity of the muscles to “reset”
FPR in general:
Easily Applied
Non-traumatic
Effective & Efficient
When performed properly patients report immediate relief of point tenderness/pain.
Treatment:
Classified into two categories:
1) one directed at normalization of palpable abnormal tissue texture
2) to influence deep muscle involved in joint mobility
1) FPR - L3 NSLRR:
Dx: L3 NSLRR or Left-Sided Erector Spinae Muscle Hypertonicity
The patient lies prone on the table
Use a pillow to flatten the curve
Monitor L3 or hypertonic tissues (Fig. 12.18)
Crosses the patient's right ankle over the left (right lumbar rotation) and
grasps the patient's right knee while sidebending the patient's legs to the
patient's left (Fig. 12.19)
Then reposition the right hand to grasp the patient's right thigh and
rotates to the right until you reach maximum tissue relaxation
Directs a force dorsally (toward ceiling) and toward external rotation
(white arrow, Fig. 12.20)
Telescoping compression through femur to L spine dysfunction
Wait 3-5 seconds and return to neutral passively either in/direct
Recheck
Contraindications:
Indication:
Myofascial or articular somatic dysfunction
Relative Contraindications:
Moderate to severe joint instability
Herniated disc where the positioning could exacerbate the condition
Moderate to severe intervertebral foraminal stenosis, especially in the presence of radicular symptoms
at the level to be treated if the positioning could cause exacerbation of the symptoms by further
narrowing the foramen
Severe sprains and strains where the positioning may exacerbate the injury
Certain congenital anomalies or conditions in which the position needed to treat the dysfunction is not
possible (e.g., ankylosis)
Vertebrobasilar insufficiency
Jones Strain/Counterstrain:
Counterstrain Neurophysiology:
As with FPR, the primary neurophysiologic mechanism affected by counterstrain is thought to be the
relationship between Iα-afferent and γ-efferent activity
If the dysfunctional segment is positioned appropriately, the fibers may return to normal length, which
decreases tension in the fibers
This reduced tension in the area of the muscle spindle eliminates the afferent excitatory impulses
This “quiets” the gamma motor gain, reducing the stretch stimuli, and eliminates the reflex activation of the
α-motor neuron
This allows the tension and hypertonicity of the muscles to “reset”
Strain-Counterstrain Essentials
Use Flexion or Extension (translate to localize)
Have tender point at the apex of the curve
SB & R according to Rx formula (for Type I and Type II dysfunctions - remember this is indirect)
Shutdown the tender point at least 70%
This position is called the position of comfort (subjective) or mobile point (objective)
Tender point: Maintain light contact
Hold positioning & tender point for:
90 seconds: everything except ribs
120 seconds: Ribs
Recheck tenderness during treatment
If you feel a therapeutic pulse fine tune your position
Slowly reposition the patient and don’t let them reposition themselves!!!
May have a peripheral neuritis of the sciatic nerve caused by an abnormal condition of the piriformis muscle
Symptoms:
Pain with sitting, standing, lying >15 min
Pain and/or paresthesia buttocks, may radiate down posterior leg,
usually stopping above the knee
Pain with rising from seated position
Pain worse with internal rotation of leg
Pain improves with ambulation
Microtrauma
“Wallet Neuritis”
Toilet sitting
Macrotrauma
Fall
Injection complication
Ischemia
Biomechanical
Postural
Somatic dysfunction
Piriformis Syndrome: Strain-Counterstrain:
Tenderpoint is usually in the belly of the muscle
Location can be found ½ the distance between the Sacral base and ILA, then ½ the distance between this
point and the Greater Trochanter
Piriformis Counterstrain:
With patient prone locate and monitor the tender
point
flex the hip on the dysfunctional side to ~135*,
while monitoring the tender point add external
rotation and ABduction until you achieve a 70%
reduction in pain
Hold for 90 seconds then return to neutral
Recheck
Psoas Syndrome:
A neuromuscular condition characterized by pain in lower back and may
radiate to hip or groin
Cause by muscle dysfunction due to spasm or strain
Shortened muscle (i.e. sitting for prolonged period; running hills, sit ups
with legs extended)
Organic causes (malignancy, AAA, abscess, appendicitis, hernia, prostatitis,
diverticulitis, OA)
Maverick Points:
Roughly 5% of counterstrain tender points will not respond to the typical pattern of treatment
Try putting the patient in the opposite position and treating the tender point
Or
Put the tender point in it’s position of ease and treat it