Download Met_and_Manipulation

Lumbar, Pelvis, & Sacrum
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Compare and contrast MET/MAP to HVLA
Know the contraindications for HVLA
Examine the differences between mobility, stability, &
strength
Palpate landmarks of the pelvis, lumbar, & sacrum
Understand the biomechanics of the pelvis, lumbar, &
sacrum
Evaluate for pelvis, lumbar, & sacral dysfunctions
Treat dysfunctions using MET/MAP for the pelvis,
lumbar, & sacrum
Practice treatment positions for HVLA manipulation of
the pelvis, lumbar, & sacrum
Muscle Energy Technique or MET
Active contraction of muscle provides
mobilization of a joint
Decrease firing of musculature using autogenic or
reciprocal inhibition
Purpose is to restore function of the joint
Alternative to Manipulation (HVLA)
Conservative Low Risk Treatment
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MET is more correctly known as MAP or
Myotatic Activation Procedure
Contract a muscle to turn down the myotatic
reflex so you can mobilize the joint
What does this mean?
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Stop the over firing of a muscle through use of an
inhibitory or reverse origin and insertion technique
using the global system
Why is this necessary?
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Muscle is in a protective range in attempt to create
stability
NEUROMUSCULAR
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Inhibitory to reduce
firing of muscle to allow
normal joint movement
Autogenic – contract
agonist to relax agonist
Reciprocal – contract
antagonist to relax
agonist
Isometric contraction of
6-8 seconds
MECHANICAL
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Reverse origin and
insertion of muscle to
apply a direct force to
restricted segment
Key is to use muscle
attached to restricted
segment
Stronger contractions
Isometric contraction of
12-20 seconds
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HVLA = Grade V Joint Mobilization
Grade V - manipulation performed at a high
velocity and low amplitude to the anatomical
end point of a joint
Treatment goals of mobilization
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Improve mobility
Stretch contractile and non-contractile tissues
Inhibit muscle tone or stretch reflex
Improve joint proprioception
Reduce Pain
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Skill based technique requiring formal training
Useful tool for the right patient
Ideal time for manipulation is ≥ 3 days post
trauma i.e.: MVA-wait 3-4 days
HVLA can be performed during acute phase
for some mechanisms of injury i.e.: poor lifting
Can you manipulate during pregnancy?
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1st trimester – HVLA or MET/MAP
2nd/3rd trimesters –MET/MAP
ABSOLUTE
CONTRAINDICATIONS
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Acute RA
Fracture/dislocation
Avascular necrosis
Malignancy
Acute myelopathy or
Cauda Equina Syndrome
Segmental spinal
instability
Aortic aneurysm
Lack of diagnosis
Patient can not tolerate
RELATIVE
CONTRAINDICATIONS
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Joint instability
Hypermobility
Bone demineralization
Bleeding disorders or use
of anti-coagulants
Arteriole insufficiency
Benign bone tumors
Scoliosis
Spondylolisthesis
Feel
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Myth #1: “Bone out of Place”
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Not putting something back into place
Out of place is a dislocation
Myth #2: “Treat the painful side”
Do not use pain as your diagnosis
 Dysfunction often on the opposite side of pain
 Pain is often an adaptation
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1. Joint
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2. Muscle
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Mechanics
Hypermobility vs. Hypomobility
Stability vs. Instability
Global Mobilizers vs. Global Stabilizers vs. Local
Stabilizers
3. Nerve
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Neurophysiology
Neurodynamics
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Hypomobility – do not achieve physiological
end-range
Hypermobility – beyond the joints’ physiological
end-range
Hypomobility does not mean stability
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Often see hypomobility with instability (class focus)
Hypermobility does not mean instability
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May see hypermobility with stability (rare)
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Stability – control of joint neutral
Instability - inability to control joint neutral
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Three Core Stability Categories:
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1. Global mobilizers – fatiguing and fast i.e.: rectus
abdominis, erector spinae, and latissimus dorsi
2. Global stabilizers – fatiguing & fast or non-fatiguing &
slow i.e.: gluteus medius and external/internal obliques
 3. Local stabilizers – non-fatiguing and slow; usually are
not movement producing i.e.: transversus abdominis,
multifidi, and vastus medialis oblique
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Stability and strength are not synonymous
May need to address both
Strengthen using global mobilizers
Stabilize using global or local stabilizers
Do you need to stabilize or strengthen first?
How does this relate to the joint?
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Articular restrictions create muscle imbalances
Local muscle damage results in global muscle trying
to take on role
Muscle spasm and pain
ASIS and Iliac Crest
PSIS and Sacrotuberous Ligament
Quadratus Lumborum
Piriformis
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ASIS – palpate from multiple angles
Iliac Crest @ L4
PSIS @ S2; palpate prone and sitting
Sacrotuberous Ligament – medial to ischial
tuberosity
Quadratus Lumborum – Lumbar TP/12th rib to
iliac crest
Piriformis – between inferior lateral border of
sacrum to greater trochanter (ER of hip with less
than 60 degrees hip flexion; IR of hip with greater
than 60 degrees)
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Sacroiliac joint (SI joint)
Movement of the ilium on the sacrum or
movement of the innominate bones
The innominate bone is formed by the fusion of
the ilium, ischium, and pubis
Movements include:
Superior/Inferior
 Medial/Lateral
 Anterior/Posterior –rotation or shear
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Anterior Rotation
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Posterior Rotation
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ASIS inferior/PSIS superior (small change)
Little to no change with sacrotuberous ligament
ASIS superior/PSIS inferior (small change)
Little to no change with sacrotuberous ligament
Upslip
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Superior ASIS , PSIS, Iliac Crest, & Ischial Tuberosity
Sacrotuberous ligament is on slack
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Objective test to determine hypomobile side
Need patient in supine with therapist over
patient
Posteriormedial glide of SI joint
Therapists’ elbows should be flexed ≈ 15°
Test each SI joint separately
Hypomobile side is the side of the dysfunction
Treat the hypomobile side
Hypomobile side may or may not be the side
which is painful
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I.e.: (+) R posterior glide test indicating a R
Anterior Rotation
Patient in L sidelying with R hip and knee flexed
and supported on therapist
 Therapist places one hand on R ASIS and one on R
ischial tuberosity
 Therapist rotates the R illium posteriorly into barrier
 Patient extends R hip against therapist for 6 seconds
 Repeat rotation followed by resisted R hip extension
three times moving further into restriction each time
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I.e.: R Anterior Rotation
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I.e.: (+) L posterior glide test indicating a L
Anterior Rotation
Patient in supine with L hip and knee flexed
 Therapist IR and AD patient’s L hip
 Therapist grabs L L/E below knee
 Therapist distracts L L/E while patient exhales
 Therapist performs HVLA thrust inducing posterior
rotation of illium
 Contraindication: ACL deficient knee
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Ie: L Anterior Rotation
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I.e.: (+) L posterior glide test indicating a L
Posterior Rotation
Patient in supine with L leg off table
 Flex patient’s R knee and stabilize with hand
 Therapist adducts and IR rotates L hip
 Therapist grips L lower leg with adductors
 Patient exhales while therapist tractions L leg into
the barrier; repeat x 3
 HVLA: traction L leg during 1st exhale then perform
thrust
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I.e.: L Posterior Rotation
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I.e.: (+) L posterior glide test indicating a L
Upslip
Patient in prone with L leg off table
 Therapist stabilizes R thigh with hand
 Therapist adducts and IR rotates L hip
 Therapist grips L lower leg with adductors
 Patient exhales while therapist tractions L leg into
the barrier; repeat x 3
 HVLA: traction L leg during 1st exhale then perform
thrust
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I.e.: L Upslip
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Need to address QL with Upslip with selfstretch/HEP, MFR, or manual stretch using
autogenic inhibition
Directions for self stretch for HEP:
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Patient in sidelying with involved QL superior
Patient flexes uninvolved weight bearing hip
Patient raises upper arm above head
Patient extends & adducts involved hip to stretch QL
I.E.: QL SELF-STRETCH FOR UPSLIP
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Dr. Sturesson at North
American Spine
Society began
research on the SI
joint in 1985.
Compared revelation
to people learning the
earth is “round”.
Research showed that
“hands on tests” or
movement tests had
poor reliability.
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Approximately 10 cm
caudally and 3 cm
laterally from the
PSIS1,2
13-27% of low back
pain can be of origin
from SIJ12
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Goode et al3 conducted a literature review of studies
assessing motion occurring in the SIJ with movement.
7 studies met inclusion criteria
Found varying amounts of degrees of motion ranging from
0.5 – 8.0 degrees depending on the axis, in-vitro vs. in-vivo
and which diagnostic imaging was used.
 Sturesson et al4 found up to 3.9 deg (mean of 2.5 deg)
around the transverse axis and translation up to 1.6 mm
(mean of 0.7 mm) using Radiostereometric Analysis (RSA)
 RSA considered gold standard for measuring movement of
joints
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Compared to C-spine: Axial rotation induces up to 10.7
deg of sidebending at C4-C5, 9.2 deg at C5-C6, and 4.0
deg at C6-C714
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Maximum of 1.3 mm at C4-C5 in a left-right translation
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Freburger et al5 wrote commentary on the
published evidence to guide examination of the
SIJ.
Potter & Rothstein6: pairs of therapists palpated
levels of PSIS, ASIS, and iliac crests in standing
and sitting in patients thought to have SIJ
dysfunction.
 (n=17); poor intertester reliability with 35%-43%
agreement between therapists.
 Assessed intertester reliability for movement tests
including: sitting and standing hip flexion, supine long
sitting, and prone knee flexion.
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Laslett and Williams7: found high intertester
reliability (64-82%) for measurements obtained
with 5 of 7 pain provocation tests including:
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Iliac compression, iliac gapping, thigh thrust, sacral
thrust, and Gaenslans.
3 out 5 postitive tests11:
 Sensitivity 91%
 Specificity 78%
 Jumps to 87% if symptoms can’t be centralized
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Broadhurst and Bond8: 3 pain provocation tests
(Patrick’s test, thigh thrust, and resisted hip
AB) to identify subjects and assign groups.
Double blind study using local anesthetic or normal
saline (control).
 Patients rated pain intensity pre to post injection,
and provocation tests were performed again.
 SIJ dysfunction was considered if there was a 70%
reduction in pain with retest.
 Saline group: no meaningful decrease in pain.
 Local anesthetic group: majority had 70% or better
improvement.
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Tullberg et al9 used intraosseous markers and
roentgen stereophotogrammetric analysis to
assess if manipulation and mobilization
affected SIJ position.
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No change in the position of the sacrum following
intervention.
Despite the lack of change using the analysis, most
of the tests that were positive prior to intervention
were determined negative post intervention.
Conclusion: intervention was successful based on
test-retest, however patient symptoms were not
reported pre- or post.
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Sacroiliac Joint: an overview of its
anatomy, function, and potential clinical
implications (Vleeming10 2012).
 A review of multiple studies (10) performed
from 1978 – 2007 revealed SIJ mobility
depends on positioning and loading however
differences are reported in the amount of
movement.
 Rotation of the sacrum around the transverse
axis at S2 (nutation/counternutation) up to 4
degrees (mean of 2.5 deg).
“A dysfunctional SIJ is normally not related to a subluxated
position of the joint, but to increased or decreased
compression/force closure due to asymmetric forces acting on
the joint.”
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Compression/force closure and increased SIJ stiffness can
be attributed to the following:
Isometric contractions of muscles that cross the pelvis ie: glute
max, biceps femoris, and erector spinae.
 Stabilizing muscles ie: transversus abdominis and multifidus.
 Asymmetrical ligamentous laxity.
Common theme amongst articles:
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Variability amongst reliability of palpation but agreement
there is motion occurring.
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Can the SIJ be a source of pain?
 Yes – confirmed with SIJ contrast provocation and anesthetic injections1,2
Is there motion in the SIJ?
 Yes – has been shown up to 8 deg nutation/counternutation in cadaveric
studies but more commonly up to 4 deg in in-vivo studies3,4,10
Can we palpate it? Test it?
 High intertester rating with pain provocation tests7
 Varying specificities and sensitivities of provocation testing although seems
to be high when clustering tests5,6,7,10
 Poor intertester reliability with palpation of motion tests5,6
 SIJ training?9
Treatment?
 Neurotomy and Intra-articular injections– Limited and limited to moderate,
respectively12
 Little to no evidence of PT treatment. No studies with comparative
randomized controlled trials of mobilization/manipulation/stabilization.
 Tullberg9 – mobilization/manipulation; Mooney et al13 - stabilization
 Is it subluxing?
 No9
Anterior and Lateral Views
Posterior View
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Sacral Base or superior border of sacrum
Sacral Sulcus medial to PSIS
Sacral Hiatus flattened area at inferior part of
sacrum; located at S5
Inferior Lateral Angle (ILA) lateral to hiatus
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Palpate from inferior position
Palpate from posterior position
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Type I mechanics: rotation and sidebending are
opposite in neutral
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I.e.: if sacrum sidebends to the L, it will also rotate R
Sacrum flexes (nutates) with lumbar extension
and exhalation
Sacrum extends (counter-nutation) with
lumbar flexion and inhalation
If contract the L piriformis sacrum rotates R
If contract R piriformis sacrum rotates L
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Oblique Axis
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Mid-Transverse Axis
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Torsions
Named by base they
originate from
ie: Left Oblique Axis
(LOA) or Right
Oblique Axis (ROA)
Flexion or Extension
Mid-Sagital Axis
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Sidebending
SIDEBENT SACRUM
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Flexed Sacrum
Extended Sacrum
I.e.: (L or R) Flexed or
Extended Sacrum
SIJ Dysfunctions
Acute
SACRAL TORSIONS
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Forward Torsion (FST)
Backward Torsion (BST)
I.e.: (L or R) Forward or
Backwards Torsion
Piriformis or L5/S1
Chronic or Acute
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Seated flexion test differentiates between two
Patient flexes in sitting with supported lower
extremities while therapist palpates both PSIS
PSIS that moves more in a superior direction is
the hypomobile side
Asymmetrical movement of PSIS
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→ sidebent sacrum
Symmetrical movement of PSIS
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→ sacral torsion
FLEXED SACRUM
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I.e.: L Flexed Sacrum
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EXTENDED SACRUM
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(+) L sitting flexion test
Deep L sacral sulcus
Inferior L ILA
Explanation: L sidebent
sacrum with R rotation;
L side is flexed; R side is
extended; (+) test on L
→ L Flexed Sacrum
I.e.: R Extended Sacrum
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(+) R sitting flexion test
Deep L sacral sulcus
Inferior L ILA
Explanation: L sidebent
sacrum with R rotation;
L side is flexed; R side is
extended; (+) test on R
→ R Extended Sacrum
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I.e.: L Flexed Sacrum
Patient in prone; therapist on dysfunction side I.e.: L
 Abduct and IR the L hip; gaps the posterior SIJ
allowing sacrum to move into extension
 Therapist puts R pisiform on L ILA and pushes
superiorly while L pisiform is on R sacral sulcus
pushing inferiorly
 Therapist applies force three times while patient
breathes in (trying to induce sacral extension which
occurs with inspiration)
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I.e.: L Flexed Sacrum
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I.e.: L Flexed Sacrum
Patient in R sidelying with therapist in front of
patient and L side or dysfunctional side up
 Rotate L patient using U/E and flex L hip forward
 Therapist palpates the L inferior ILA while
straddling L L/E and holding patient at elbows
 Rotate patients’ L hip until sacrum faces ceiling (L/E
may reach floor)
 ASIS of therapist against ischial tuberosity of patient
 Take up slack during exhalation
 Therapist thrusts hip and drops while driving
inferior ILA in a superior direction
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I.e.: L Flexed Sacrum
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I.e.: R Extended Sacrum
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Patient in prone on elbows positioning & therapist
on opposite side of the dysfunction side I.e.: L
Abduct and ER the R hip; gaps the anterior SIJ
allowing sacrum to move into flexion
Therapist stabilizes R iliac crest with R hand, and
applies anterior force at R sacral sulcus with L hand.
Therapist applies force three times while patient
breathes out (trying to induce sacral flexion which
occurs with exhalation)
I.e.: R Extended Sacrum
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I.e.: L Extended Sacrum
Patient in R sidelying with therapist in front of
patient and L side or dysfunctional side up
 Rotate L patient using U/E and flex L hip forward
 Therapist palpates the L sacral sulcus while
straddling L L/E and holding patient at elbows
 Rotate patients’ L hip until sacrum faces ceiling (L/E
may reach floor)
 ASIS of therapist against ischial tuberosity of patient
 Take up slack while patient exhales
 Therapist thrusts hip and drops while driving in
perpendicular direction inducing sacral flexion
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I.e.: L Extended Sacrum
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Special Test to differentiate between the two
Patient in prone
Palpate sacral sulci – note positions
Patient moves from prone to prone on elbows
Palpate sacral sulci – note positions
In extension both sulcus depth even
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→ FST
In extension sulcus depth uneven
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→ BST
Differentiates between FST and BST
FORWARD SACRAL
TORSION
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I.e.: L FST
BACKWARD SACRAL
TORSION
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Base of sacrum forward
Deep R sacral sulcus and
posterior L ILA in prone
 = depth of sulci with
extension
Base of sacrum backwards
Deep R sacral sulcus and
posterior L ILA
 ↑ R sulci depth with
extension
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Explanation: sacrum
flexes with lumbar
extension; L side of base
will and does flex
forward; evens out sulci
I.e.: L BST
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Explanation: L - L5/S1
facet will not flex with
extension but R facet will
flex ; R sulcus appears
deeper
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I.e.: Left Forward Sacral Torsion (FST)
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Dysfunction is with R piriformis
Lie patient on R side (dysfunction side down)
Rotate upper body to the L to level of L5
Flex both hips < 60° (keeps piriformis as a hip ER)
Lift both legs inducing ER of R hip and IR of L hip
Resist patient pulling legs to floor, inducing ER of
the L hip
ER of L hip inhibits R piriformis
Perform 3 x for 6 seconds each while moving further
into restriction
I.e.: L FST
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I.e.: Left Forward Sacral Torsion (FST)
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Dysfunction is with R piriformis
Lie patient on R side (dysfunction side down)
Induce L rotation and extend bottom leg (do not lock
bottom leg into extension; more flexion)
Flex the L hip forward and hook using bottom leg
(sacrum not facing ceiling as in sidebent sacrum)
Therapist palpates L posterior ILA and line of drive
determined from position of forearm (must use
posterior ILA b/c can not manipulate piriformis)
Therapist takes up slack while patient exhales
Therapist performs HVLA with drop (not hip thrust)
I.e.: L FST
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Need to address piriformis with FST with
stretch using uninvolved piriformis or
quadratus lumborum (reciprocal inhibition)
Directions for stretch using QL:
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Patient supine; therapist holds involved L/E
Hip flexed > 60°; piriformis is now hip IR
Knee in midline & hold ankle stretching into hip ER
Patient using QL to hike hip → relax x 3 times
I.e.: R piriformis stretch for L FST
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I.e.: Left Backwards Sacral Torsion (BST)
Lie patient with restricted L L5/S1 up
 Therapist induces L rotation to L5
 Extend bottom leg to S1 to induce sacral flexion
 Flex the L hip off table to gap L L5/S1 joint
 Resist patient lifting L leg superiorly
 Perform 3 times for 6 seconds each time with patient
relaxing in between and therapist moving patient
into restriction
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I.e.: L BST
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I.e.: Left Backwards Sacral Torsion (BST)
Lie patient with restricted L L5/S1 up
 Induce L rotation until feel movement at sulcus
 Extend bottom leg to S1 to induce sacral flexion
 Flex the L hip to gap L L5/S1; hook with bottom leg
(sacrum not facing ceiling as in sidebent sacrum)
 Therapist palpates L sacral sulcus and line of drive
determined from position of forearm
 Therapist takes up slack while patient exhales
 Therapist performs HVLA with drop (not hip thrust)
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I.e.: L BST
Anterior, Lateral, and Posterior Views
Posterior and Lateral Views
Superior View
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Spinous Processes L1 through L5
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Iliac crests and over to L4 spinous process
Transverse Processes of L1 through L5
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TP are 1-2 thumb widths lateral to spinous processes
TP of L5 are superior and approximately 30 degrees
medial to PSIS
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Laws of Vertebral Motion:
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Type I Dysfunctions:
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SB and rotation are opposite in neutral
SB and rotation are same in flexion and extension
Motion taken up in one plane; all other motions ↓
Motion lost to dysfunction ; all other motions adapt
In neutral with SB and rotation opposite
Multi-segmental and adaptive
I.e.: OA joint, T1-L5, and Sacrum
Type II Dysfunctions:
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In flexion/extension with SB and rotation same
Single segmental and traumatic
Ie: C2-C7 and T1-L5
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Positional Dx:
FRSL
FRSR
ERSL
ERSR
Motion Restriction:
ERSR
ERSL
FRSR
FRSL
Restricted Facet:
Right
Left
Left
Right
Posterior TP:
Left
Right
Left
Right
I.e.: FRSL Positional Dx:
 Rotation is named by direction of the vertebral body
 Segment is in a position which is flexed, rotated and
sidebent L
 Motion is restricted in extension, rotation and
sidebending R
 Restricted facet on R
 More posterior TP on L
ERS DYSFUNCTION
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Type II Dysfunction
Name dysfunction by the
positional Dx
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I.e.: ERSL or ERSR
Found in flexion
Feel for ↑ posterior TP
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FRS DYSFUNCTION
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I.e.: posterior R TP =
positional Dx of ERSR and
motion restriction of FRSL
Position and treat into
motion restriction = FRSL
Type II Dysfunction
Name dysfunction by the
positional Dx
Found in extension
Feel for ↑ posterior TP
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I.e.: FRSL or FRSR
I.e.: posterior R TP =
positional Dx of FRSR and
motion restriction of ERSL
Position and treat into
motion restriction = ERSL
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I.e.: Positional Dx ERSR L4
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



Found in lumbar flexion with R posterior TP
Restricted facet is on the R
Motion restriction = treatment position of FRSL
Patient in R sidelying (L side up); therapist in front
Rotate patient L from top to L4/L5 SP gap
Flex patient from bottom to L4/L3 SP gap
Lift leg(s) off table inducing L SB
Resist patient pushing down with leg(s) for 6 sec
Repeat x 3
I.e.: Positional Dx: ERSR L4

I.e.: Positional Dx ERSR L4









Found in lumbar flexion with R posterior TP
Restricted facet is on the R
Motion restriction = treatment position of FRSL
Patient in R sidelying (L side up); therapist in front
Rotate patient L from top to L4/L5 SP gap
Flex patient from bottom to L4/L3 SP gap
Cross patient’s arms with bottom arm over top
Therapist stabilizes @ elbows and L hip/knee
Therapist performs HVLA by pushing ↓ on L L/E during
exhalation; induces L rotation and flexion @ L4
I.e.: Positional Dx: ERSR L4

I.e.: Positional Dx ERSR L4









Found in lumbar flexion with R posterior TP
Restricted facet is on the R
Motion restriction = treatment position of FRSL
Patient in R sidelying (L side up); therapist in front
Rotate patient L from top to L4/L5 SP gap
Flex patient from bottom to L4/L3 SP gap
Therapist stabilizes at elbows or weaves arm through
patient’s elbows
Therapist stabilizes @ torso and across L hip/buttock
Therapist performs HVLA driving towards self/floor
during exhalation; induces L rotation and flexion @ L4
I.e.: Positional Dx: ERSR L4

I.e.: Positional Dx FRSR L4
Found in lumbar extension with R posterior TP
 Restricted facet is on the L
 Motion restriction = treatment position of ERSL
 Patient in R sidelying (L side up); therapist in front
 Rotate patient L from top down to L4/L5 SP gap
 Extend patient from bottom up to L4/L3 SP gap
 Lift leg off table inducing L SB
 Resist patient pushing down with leg(s) for 6 sec
 Repeat x 3

I.e.: Positional Dx: FRSR L4

I.e.: Positional Dx FRSR L4









Found in lumbar extension with R posterior TP
Restricted facet is on the L
Motion restriction = treatment position of ERSL
Patient in R sidelying (L side up); therapist in front
Rotate patient L from top down to L4/L5 SP gap
Extend patient from bottom up to L4/L3 SP gap
Cross patient’s arms with bottom arm over top
Therapist stabilizes @ elbows and L hip/knee
Therapist performs HVLA by pushing ↓ on L L/E during
exhalation; induces L rotation and extension @ L4
I.e.: Positional Dx: FRSR L4

I.e.: Positional Dx FRSR L4









Found in lumbar extension with R posterior TP
Restricted facet is on the L
Motion restriction = treatment position of ERSL
Patient in R sidelying (L side up); therapist in front
Rotate patient L from top to L4/L5 SP gap
Extend patient from bottom to L4/L3 SP gap
Therapist stabilizes at elbows or weaves arm through
patient’s elbows
Therapist stabilizes @ torso and across L hip/buttock
Therapist performs HVLA driving towards self/floor
during exhalation; induces L rotation and extension @ L4
I.e.: Positional Dx: FRSR L4









Emerson P 2004 MET: of the Lumbar, Pelvis, and Sacrum, Denver.
Emerson P 2005 High Velocity Low Amplitude Manipulation, Denver.
Schofield A K 2006 Core Stability Training: The Performance Matrix,
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Pluemer J. Joint Mobilization, and Overview of Maitland Techniques.
Manual Therapy. 2005.
Netter, Frank H., Atlas of Human Anatomy-Second Edition, Novartis,
1997.
Moore, Keith L., Clinically Oriented Anatomy-Fourth Edition, Williams
& Wilkins, 1999.
Richardson, Jan K., Clinical Orthopedic Physical Therapy, W.B. Saunders
Company, 1994.
Smith, Laura K., Brunnstrom’s Clinical Kinesiology-Fifth Edition, F.A.
Davis Company, 1996.
Bernhardt A. SIJ Movement. In-service. 2016.
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