INTRODUCTION SACRO ILIAC JOINT• 3. Enhance self‐regulatory systems of the body to restore functionality, well being and reduce pain • 4. Treat both soft tissues and osseous (articular)

MSDWMANIPULATION SKILL

DEVELOPMENT WORKSHOPINTRODUCTION

SACRO‐ILIAC JOINTNICK BURATOVICH, NMD

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MSDW - Manipulation Skill Development Workshop • INTRODUCTION SACRO‐ILIAC JOINT Instructor: Nick Buratovich, NMD • TheBoneDance.com

SPINAL MANIPULATION:THE BONE DANCE

• There is a rhythm,choreography to manipulation:a beginning, a middleand an end.

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PHYSICAL MEDICINE

• BASIC PRINCIPLES:

• 1. Restore structural integrity (structure governs function)• 2. Recognize the value of individuation of therapy: lesion specific (fixation/misalignment) and constitutional treatment (tonic/reflex)

• 3. Enhance self‐regulatory systems of the body to restore functionality, well being and reduce pain

• 4. Treat both soft tissues and osseous (articular) structures

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PHYSICAL MEDICINE

• BASIC PRINCIPLES:

• 5. Use minimum force• 6. Stimulate circulation of blood/lymph/nerve flow to increase vitality and health

• 7. Magnetic treatment – intention• 8. Educate the patient for self‐care and movement dynamics (exercise)

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PHYSICAL MEDICINE

• CONCEPT OF THREE:• 1. Targeted specificity

• Manipulating an individual vertebra• 2. Functional specificity

• Manipulating one vertebra affects the one above and below• Manipulating the right side will affect the left side

• 3. Pop and pray

• Consider intention• You don’t always need a cavitation

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OSSEOUS MANIPULATION

• WHY DO WE USE OSSEOUS MANIPULATION?• Restore motion (joint play)• Restore alignment• Repair tissue texture abnormalities• Reduce pain• Stimulate reflex effects (visceral)• Treat psychosomatic conditions• To stimulate the VIS

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INDICATIONS FOR MANIPULATION

• THE TWO PRIMARY INDICATIONS FOR MANIPULATION ARE:• 1. LOSS OF JOINT PLAY: Fixation/restriction/hypo‐mobility• 2. MALPOSITION: Asymmetry of joint position• LEADING TO:• PAIN: Sensitivity, tenderness • ALTERATION IN TISSUE TESTURE: Tension, fibrosis of repair

• STAR• Reflex effects, psycho‐somatic issues, stimulate the vis

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JOINT PLAYNormal movement of the spine occurs in the following directions:

Flexion and Extension

Rotation: right and left

Lateral Bending (lateral flexion) : right and left

The spine is also able to distract (stretch) or compress (pull together) in relationship to the force of gravity.

These movements are active movements which the patient can do.

In addition there is an involuntary or accessory movement which has been described by Dr. John Mennell. This is joint play. Joint play are intrinsic movements of all synovial joints which are not under the voluntary control of the voluntary muscles and are demonstrable in every normal joint. Even though joint play cannot be isolated or produced by the action of the voluntary muscles, voluntary action depends on normal joint play.

Joint play can be found in the para-physiological space and is determined by the physician applying pressure and movement to the joint at the rate of about 1 - 3 oscillations per second. The physician is feeling for joint end-feel or spring and pain. Loss of joint play produces pain whenever the specific direction of loss is tested by the physician

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PRONE LEG LENGTH EVALUATION

• In a prone patient the leg length may be evaluated by comparing the relative position on the medial malleolus of each ankle• The patient may position themselves on the table by first kneeling and then laying face down (prone)• The doctor may also use a hydraulic table which lowers and raises the patient in a stable prone position• The patient should be laying straight • Once the patient is in position the doctor may grasp the ankles of the patient and place the thumbs on the corresponding malleolus

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• The doctor applies a slight but equal distraction or compressive force on the legs to provide a balance point• The thumbs should be placed on the distal(inferior)aspect on the malleoli with a slight pressure applied in a cephalad direction• The fingers drape over the external/lateral aspects of the ankles and are passive• The hands may bring the ankles together to better view the position of the thumbs

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• Once the hands are placed the doctor may view for symmetry of their thumbs (dominant eye)• In a patient with equal leg length (pelvic symmetry) the thumbs should be also be in the same vertical plane• In a patient with a short leg the leg that is short will show a cephalad thumb• By convention the short leg is usually referred to as the reference point of imbalance

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• Some doctors may elect to use their index fingers as a marker for leg length position• In this case the index finger may reach from underneath the ankle and be placed in a symmetrical position on the malleoli and then evaluated for relative position• This is either by personal preference of due to hand/ankle size

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• Other factors used to evaluate SI imbalance are:• Thickening in the Achilles tendon• Tenderness in the area between the medial malleolus and the Achilles tendon• Tension in the muscles of the lower extremities• Tenderness to palpation in the sacral sulcus and LS area

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SHORT LEG

• In patients with a short leg the cause may be either anatomical or functional• An anatomical short leg is due to a shortened femur or tibia/fibula

• Congenital / traumatic

• A functional short leg is due to a pelvic imbalance (90‐95% )• This is commonly a result of a spinal or pelvic imbalance such as a posterior rotation of the lumbar vertebra or scoliosis

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PELVIC ASYMMETRY

• PI (posterior ilium)• The ilium is rotated posterior (flexed)

• Short leg/inferior PSIS/high iliac crest/high GT

• AS (anterior ilium)• The ilium is rotated anterior (extended)

• Long leg/superior PSIS/low iliac crest/low GT

• PELVIC SHEAR• The ilium is superior

• Short leg/superior PSIS/high iliac crest/high GT

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SUPINE LEG LENGTH EVALUATION

• In a supine patient the leg length may be evaluated by comparing the relative positions of the medial malleolus of each ankle as well as the position of the ASIS’s, iliac crest and GT• To eliminate any artifact of position the patient may bring their knees up and lift their pelvis off the table• If there is still a short leg (pelvic asymmetry) the patient may perform the supine to sitting test to determine if the short leg is functional or anatomical

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SUPINE TO SITTING TEST

• If the malleoli retain the same position in the supine as sitting position then it may be an anatomical short leg (heel lift)• If the inferior malleoli lengthens then it may be a functional short leg (manipulation)• May also measure the length of the ASIS to the medial malleolus or the length of the GT to the lateral malleolus to compare the length of the legs to determine a functional vs anatomical short leg• May use X‐rays to determine functional vs anatomical short leg

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PELVIC SYMMETRY

• STATIC ASSESSMENT:• Prone: PSIS / iliac crest / GT / ASIS in supine pt

• Using the PSIS’ as a landmark begin your palpation with an open palm feeling for the PSIS with the area between your thenar and hypo‐thenar eminences. • Once located position your thumbs underneath the PSIS for a standard position by moving your thumbs in a cephalad direction ‘hooking’ under the inferior aspect of the PSIS

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PELVIC SYMMETRY

• STATIC ASSESSMENT con’t:• Once your thumbs are placed you may evaluate their position relative to a horizontal plane to see if they are even (normal) or if one is inferior or superior.• The inferior PSIS is usually associated with a short leg on the same side. (PI) You will also see a superior crest and GT.• The superior PSIS may be associated with a pelvic shear or anterior ilium (AI) on the same side• You may also evaluate horizontal leveling of the iliac crests and the greater trochanters

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PELVIC SYMMETRY‐PSIS

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PELVIC SYMMETRY ‐ PSIS

EQUAL UNEQUAL

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JOINT PLAY:MOBILITY ASSESSMENT

• Once the PSIS’ are identified they may be evaluated for joint play in the prone position• The doctor stands at the side of the patient at the level of the pelvis facing the pelvis of the prone patient • The cephalad hand contacts the PSIS in the area between the thenarand hypo‐thenar eminence, laying flat • The ulnar pisiform area of the caudad hand is placed on the superior aspect of the corresponding side upper sacrum

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JOINT PLAY:MOBILITY ASSESSMENT

• With movements from the shoulder girdle and with the arms held straight pressure is applied in an alternating fashion on the SI joint appreciating joint play• The doctor then repositions their hands on the opposite side SI j0int and repeats the evaluation• As the sacrum is medial to the PSIS the contact hand on the sacrum should be medial to the contact hand on the PSIS for each side• The doctor compares the joint play of each SI joint and determines which one is less mobile. The joint with the less movement is the one with the restriction (fixation)

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JOINT PLAY – SI JOINT

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JOINT PLAY – SI JOINT

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BASIC POSITION: L/S REGION

• The patient lies on the side with the short leg, lesion, side up• Tabled arm is tractioned with rotation of the trunk towards a supine position and resting the hand on the opposite shoulder ball (may also ‘stack’ the shoulders)• Superior arm rests on the lower rib cage or the hands may rest together on the rib cage. • Patient should look to the ceiling• Tabled leg is straight• Top leg has the knee and hip flexed with the foot resting in the popliteal fossa of the tabled leg

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• In the side‐lying position to evaluate joint play of the S/I joint the doctor uses the cephalad hand to contact and stabilize the shoulder to the table• The caudad hand palpates the PSIS• The doctor ‘grasps’ the distal femur and proximal tibia/fibula between their legs facing the patient• The doctor begins to flex and extend the LE of the patient while the PSIS is being palpated. • When the point of maximal movement is felt that is the position used for manipulation of the SI joint

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VERTICAL SKIN TRACTION

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PALPATION OF THE C‐SPINE

• BONY PALPATION:• ANTERIOR:

• Hyoid bone (C3)• Thyroid cartilage (Adams Apple) (C4‐C5)

• POSTERIOR:• Occiput / Inion• Mastoid processes• TP C1• SP C2• Facet joints (C5/6 most involved in pathology)• C7 / T1 Vertebrae prominens

• SOFT TISSUE PALPATION:• SCM muscle, lymph node chain, trapezius muscle, suboccipital muscles

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PALPATION OF THE T‐SPINE


• Sternum: manubrium (R1), body, xiphoid process• Clavicle (proximal/distal)

• POSTERIOR:• Spinous processes T1 – T12• Transverse processes , rib heads and rib angle• Scapula: spine (T3), superior angle (T2), inferior angle (T6‐7), vertebral border

• SOFT TISSUE PALPATION:• Trapezius muscle, levator scapula muscle, rhomboids, intercostal muscles, pectoralisgroup

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PALPATION OF THE L‐SPINE


• Vertebral bodies• POSTERIOR:

• Spinous processes (L1‐5)• Transverse processes• Facet joints• Lumbosacral junction

• SOFT TISSUE PALPATION:• Supra‐spinous and inter‐spinous ligaments, para‐spinal muscles, anterior abdominal muscles, iliopsoas muscle

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PALPATION OF THE HIP & PELVIS


• ASIS• Iliac crest (level or unleveled)• Greater trochanter• Pubic symphysis

• POSTERIOR:• PSIS (level or unleveled)• Ischial tuberosities• SI joint• Sacrum / coccyx

• SOFT TISSUE PALPATION:• Inguinal ligament, adductor longus muscle, iliopsoas, sciatic nerve, pyriformis, gluteal group, hamstrings

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Principles of HVLA Thrusting (Mobilization Technique with Impulse)

• High-velocity, low-amplitude thrust technique is one of the oldest and most widely used forms of manual medicine. Known as Manipulation, or Mobilization Technique with Impulse. Used to treat a "manipulable lesion" or "fixation" based on loss of joint play or malposition.

• There is some evidence that the effect of a thrust with an audible pop is a "cavitation" phenomena in the joint where the synovial fluid changes from a liquid to a gaseous state. This can be seen on X-Ray where there is the appearance of a gas shadow within the joint which persists for about 20 minutes. Also, following the thrust there is a temporary electrical silence of the segmental muscles, with a refractory period before electrical activity returns.

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Principles of Technique Application• 1. JOINT GAPPING: With a successful thrust there is some element of joint

distraction and gapping. It is the joint gapping which results in the audible "pop" or "click".

• 2. LOCALIZATION: Localization limits the thrust to the joint needingtreatment. Localization involves the application of levers and locking. Levers are long or short. The short lever is one in which a portion of one vertebra (SP) is held firmly while force is applied to a bony prominence of the adjacent vertebra (SP, TP, MP); the force is applied with sufficient velocity to move one segment on the other. Long levers involve the use of either one of the extremities or multiple segments within the vertebral column in a "locking" maneuver.

• 3. VELOCITY: Velocity means speed not force. The maneuver should have quickness. The common mistake is a "push" and not a "quick thrust".

• 4. AMPLITUDE: The thrusting force should be applied quickly and for a short distance. (1/8th inch)

• 5. BALANCE AND CONTROL: Both the operator and the patient must be in body positions that are comfortable, easily controlled and balanced.

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KEYS TO SUCCESSFUL MANIPULATION

• 1. POSIOLOGY• This is the proper position of the doctor and patient

• 2. CONTACT• This is the proper contact point for the doctor and patient, eg. The doctors pisiform on the pt’s PSIS

• 3. LINE OF DRIVE• This is the direction of the force of the thrust• This is determined by the LISTING of the lesion (the direction of correction

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KEYS TO SUCCESSFUL MANIPULATION

• 4. TAKE OUT SLACK: This is to take the slack out in the :• Soft tissues / osseous tissue• Table cushion• Doctor’s thrusting arm and leg

• 5. THRUST MECHANICS: This involves the velocity (speed) and the amplitude (distance/depth) and the manner of the thrust• It is a dynamic thrust not a push. Don’t scissor. There are several types of thrust mechanics• Recoil (T‐spine)/body drop/leg kick/cradle and chin hold

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BASIC CONCEPTS IN MANIPULATION

• The body drop (lunge/genuflection)• This is a skill to master in manipulation• It is done primarily in the lumbosacral region• The thrust is applied through a rapid drop of the weight of the entire body through the stance leg

• The kick• Also a skill to master and done in the L/S region• The thrust is applied through a rapid ‘kick’ of the lower extremity

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BASIC POSITIONS

LUNGE KICK

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• Pre‐Thrust Mobilization (PTM) Rock, Lock & Drop• Before applying the thrust total relaxation is prerequisite• This is accomplished through passive mobility, or oscillatory motion• One begins manipulation with a slight rocking and stretching• Don’t confuse guarding and inability to relax, some patients don’t know how to relax, they will not be able to relax even when passive motion causes no pain

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• Always treat soft tissues as well as joints• Lateral, longitudinal stretch, separation of origin and insertion, deep pressure

• Used to prepare tissues• Have mechanical, circulatory (lymphatic), neurological (reflex) and constitutional (tonic) effects• Increases a sense of well‐being• Repetitive oscillatory movements (joint play) and ROM

• Since all have therapeutic effects may make diagnosis more difficult

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RED /YELLOW FLAGS FOR SPINAL MANIPULATION

• Red flags are objective clinical indicators of severe spinal pathology with diagnostic danger signs and physical risk factors which usually lead to further medical interventions

• Yellow flags are subjective psychosocial risk factors which are indicative of possible long term chronicity and disability creating barriers to recovery which lead to cognitive or behavioral interventions

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UNTOWARD REACTIONS

• FUNCTIONAL REACTIONS• Perspiration, generalized tremor, nausea, epigastric pain, early or heavy menstruation, dizziness, fatigue

• PAINFUL REACTIONS• Post‐manipulative diffuse pain

• Adhesion release• Post‐manipulative aches and pains

• Ligament, muscle, fascia stretching• Headache, radiating discomfort

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UNTOWARD REACTIONS

• These reactions are typically seen in 30 – 50% of patients• Usually may last several minutes to hours but usually less than 24 hours• Other forms of treatment have the same type of side effects• Physical therapy• Exercise• Medications

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BASIC POSITION:SHOULDERS STACKED

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BASIC POSITION:HAND ON HAND ON SHOULDER

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BASIC POSITION:HANDS TOGETHER

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BASIC POSITION:HAND ON UP‐SIDE ELBOW

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THIGH CONTACT FOR JOINT PLAY

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ILIAC EXTENSION RELEASEPI ILIUM / SHORT LEG

• The ilium is rotated posterior and stuck in flexion and restricting extension. The release is to extend the ilium. This is a direct technique, engage the restriction (extension) and thrust through it.• L: Restriction against unilateral iliac extension• PP: Basic SI release position, LESION SIDE UP• DP: Basic SI position, facing cephalad• CH: Caudad (table side) hand using pisiform contact on upside PSIS. Forearm lines up in the direction of the femur

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• IH: Patient’s upside shoulder ball or elbow• TT: In an ark from inferio‐medial to supero‐lateral• PTM: While in position rock the patients body back and forth feeling for relaxation. Includes varying degrees of iliac extension traction with trunk torsion and rocking the pelvis back and forth maintaining the tension between the contact and indifferent hands.• TM: (Lunge) The doctor’s thigh creates rotational (downward) torsion through flexion traction. Thrust by body drop as contact hand (pisiform) moves the PSIS in an anterior direction so as to extend the ilium while the doctor’s leg rapidly flexes causing ilium extension

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ILIAC EXTENSION RELEASE:LUNGE

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DISTAL LATERAL FEMUR CONTACT

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• TM: (Kick) The doctors anterior knee contacts the patient’s proximal lateral foreleg/knee. Thrust by a kicking motion, like starting a motorcycle or kicking a ball as the contact hand (fingers)moves the PSIS in an anterior (forward rotation) direction so as to extend the ilium

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ILIAC EXTENSION RELEASE:KICK TECHNIQUE

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PELVIC SHEAR / SHORT LEG

• L: Pelvic shear with ipsilateral short leg• Short leg, high PSIS, high crest, high GT

• PP: Patient lies supine• DP: Standing at the foot of the table, or sitting next to patient• CH/IH: Position #1: Doctor grips the leg distal to malleoli. Position #2: Doctor sits next to patient and with fingers interlaced grabs the proximal thigh. The LE is placed over the doctors shoulder• TT: slack is taken out by distraction of LE

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PELVIC SHEAR

POSITION #1 POSITION #2

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ANTERIOR ILIUM / LONG LEG

• The ilium is rotated anterior (extended) and this creates a long leg, a superior PSIS, low crest, low GT• L: An anterior rotated ilium with a long leg• PP: Basic position, LESION SIDE UP• DP: Basic position• CH: pisiform contact on upside ischial tuberosity• IH: Patient’s upside shoulder ball • TT: Slack is taken to flex the ilium (pelvis) by pisiform contact

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ANTERIOR ILIUM / LONG LEG

• PTM: While in position rock the patients body back and forth feeling for relaxation. Includes varying degrees of iliac/thigh flexion traction with trunk torsion and rocking the pelvis back and forth maintaining the tension between the contact and indifferent hands.• TM: Considerable traction into thigh flexion is imparted by the Dr’sthigh to leg contact. A thrust is imparted to upside ischial tuberosity so as flex the ilium. Thrust by body drop into flexion.

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ANTERIOR ILIUM

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Documents

INTRODUCTION SACRO ILIAC JOINT• 3. Enhance self‐regulatory systems of the body to restore functionality, well being and reduce pain • 4. Treat both soft tissues and osseous (articular)