Download Lecture 1 - Evaluation and Treatment of Lumbar Somatic Dysfunction

Lecture 1 - Evaluation and Treatment of Lumbar Somatic Dysfunction
Lumbar Region
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Frequent site for strain, pain, and disability
Back Pain-affects 85% of all of us at some time.
1. Most common reason for limited activity in people less than 45 years of age.
2. 2nd most frequent reason for visits to physician. 2nd leading cause for work
absenteeism.
3. 5th most common reason for hospital admissions.
4. 3rd – surgical procedures.
5. Large number of workers compensation claims.
Low Back Pain
1. Most cases of LBP or Sciatica resolve spontaneously in 2 weeks.
2. Minority take 6-12 weeks.
3. Only 1-2% should require surgery.
Interconnectivity (Lumbar aponeurosis and fascia)
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Allows functional attachments to:
o Gluteal mm
o Hamstrings
o Iliotibial band to lower extremity
o Upper Extremities via latissimus dorsi mm
Developmental Curves
Development of the Secondary Curves
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Cervical curve
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Develops as the child begins to hold its head up
Lumbar curve
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Develops as the child begins to stand and walk
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“Lumbar Lordosis”
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Backward bending curve
Lecture 1 - Evaluation and Treatment of Lumbar Somatic Dysfunction
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Functionally permits more extension than flexion
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Normally can flex 40 degrees, extend 30 degrees.
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*Large portion of low back pain is from lordosis
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“Sagittal Plane Somatic Dysfunction”  too extended/flexed
Somites
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dorsal mesoderm on either side of notochord
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arranged in pairs: 4 occipital, 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 8-10 coccygeal
Sclerotome
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1st significant change in somite of human embryo
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cluster of mesenchymal cells
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aggregate around notochord to give rise to vertebral column and ribs
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clustering of sclerotomal cells on either side of notochord give rise to body or “centrum of
vertebrae”
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paired mesenchymal cells extend:
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dorsally- primordium of neural arch
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laterally- costal processes
Dermatome – area of skin supplied by cutaneous braches from a single spinal nerve.
Myotome – portion of mesodermal somite that gives rise to skeletal muscle.
Sclerotome – group of mesenchymal cells of the somite (located on each side of the notochord) that
become centrum of vertebrae and ribs. Also become joint capsule, ligaments, & bone.
Functional Anatomy
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Lumbar Vertebral Body
o Large cross-sectional area
o Longitudinal and vertical trabecular arrangement
 Sustain heavy, functional longitudinal loads
o Hematopoiesis
Pedicles
o connect post elements to vertebral body
Lecture 1 - Evaluation and Treatment of Lumbar Somatic Dysfunction
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lumbar nerve winds around the pedicles, then exist intervertebral foramen before it
crosses disc.
o AP Radiograph: Pedicle- 2 longitudinal rows of opaque ovals.
Spinous processes (SP)
o Larger, Quadrangular (spade-shaped)
o Directed dorsally in horizontal plane
• Transverse Processes
o Long, thin
o Directed laterally in horizontal plane
o *In same plane as corresponding spinous process.
Lamina
o Project medially and caudad from pedicle
o End to form the spinous processes
o “Spina bifida”
 Lamina do not completely meet to form SP  Opening where SP should be
Spinous Process
o Same horizontal plane as TP of corresponding vertebrae
o Quadrangular spade-like
o L5 SP is smaller Feels more like Thoracic SP
 *easy to identify L5 as the last lumbar vertebrae
Spinal Canal
o Wider transversely than AP
o Spinal cord  Ends L2-L3, becomes “cauda equina”
Lumbar vertebrae
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Large strong vertebral body(larger than other vertebrae)
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Rectangular shaped spinous process
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2 short stubby transverse processes
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No costal facets
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No foramina in transverse processes
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Vertebral body higher in front than back
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Intervertebral disc higher in front than back
Superior articular facets
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concave
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“BUM”- backward, upward, medial
Lecture 1 - Evaluation and Treatment of Lumbar Somatic Dysfunction
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Inferior articular facets
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convex
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forward, downward, lateral
Zygopophyseal Joint  formed by superior and inferior facets
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zygopophyseal tropism (facet asymmetry)  most common congenital abnormality
(30% of patients)
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Larger body
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Thicker and short TP
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Smaller SP higher anteriorly, distal end 1/3 smaller, feels more like a thoracic SP
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*largest number spinal congenital defects occur at this level.
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Lumbosacral anomalies fairly common.
L5
Intervertebral Discs
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total: ¼ length of spine
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nucleus pulposus-compressible, 70-90% water
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annulus fibrosus
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thick anteriorly, thin posteriorly
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holds nucleus and gives form to it
Nucleus pulposus + Annulus fibrosus  work synergistically as a “shock absorber”
Disc Herniations
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Posterior Herniation (central)  disc protrudes posteriorly and dural sac is indented at that
level on MRI
o Cauda equine syndrome  surgical emergency
Posterolateral Herniation  may compress the spinal nerves as it passes through the
intervertebral foramen (Red Flag  pain that goes below the knee)
o If more medially positioned, the herniation may spare the nerve at that level, but impact
nerves at inferior levels
Spinal Dysraphism
Lecture 1 - Evaluation and Treatment of Lumbar Somatic Dysfunction
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Spina bifida occulta  failure of closure of lamina
o Fat pad overlying
o Tuft of hair or only skin dimple may be present, or there may be no external
manifestations
o Dermal sinus may also be present
o Protrusions
 Meningocele  CSF sac protruding
 Meningomyelocele  Spinal cord and CSF fill sac
 Possible paralysis
o Open
 Central cicatrix
Bony Asymmetry
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30-40% of the population have congenital osseous asymmetry
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Facet asymmetry  One facet is in a different plane (MOST COMMON)
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Sacralization  “The Batwing Deformity”  sacrum fused to the transverse process of
L5
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Lumbarization  S1 becomes L6, then only S1 – 4 remaining
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Spina bifida occulta
“Scotty Dog”  oblique view
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ear – superior articular process
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eye – pedicle
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nose – transverse process
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foreleg – inferior articular process
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hindleg – spinous process
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head – transverse process
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body – spinous process & lamina
Stress Fx of Pars Interarticularis
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“Spondylolisis” – collar (fracture) on scotty dog
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“Spondylolisthesis” – forward slippage of vertebrae
Structural Integrity
Lecture 1 - Evaluation and Treatment of Lumbar Somatic Dysfunction
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Anterior Longitudinal Ligament
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C2 to sacral base
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broader and thicker than Posterior Longitudinal ligament
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Limits extension
Posterior Longitudinal Ligament  limits flexion
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Continuous from C spine to L spine
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Narrows as it reaches the L spine
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makes posterolateral portion vulnerable to disc herniation
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herniation most common between L4 - L5 and L5 - S1
Disc vs. Deficit
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X+1 Rule
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Herniation at disc X affects nerve root X+1
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Nerve root X will have already exited the foramina and will be unaffected
Lumbar Anatomy: Ligaments
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Iliolumbar Ligaments
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Attachment at L4 and L5 transverse process
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Increase stability at the lumbosacral junction
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Commonly strained in traumatic injuries
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One of the 1st areas to become tender with postural stress and decompensation
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“I think I have a hernia.”
Lumbar Anatomy: Musculature
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Diaphragm
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Left Crus attaches at L1-2
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Right Crus attaches at L1-3
Psoas
Lecture 1 - Evaluation and Treatment of Lumbar Somatic Dysfunction
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origin: ant portions of lumbar vertebrae near insertion of crura
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inserts: with iliacus as “iliopsoas” into Lesser Trochanter (flex/sidebend when injured)
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Quadratus lumborum
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Major role in synergistic activities of low back mm in maintaining normal LS
angle and proper postural balance.
Attachments
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12th rib – functions with respiration (extending/sidebent when injured)
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Iliac crest
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Vertebral column
Motion
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Bilateral contraction – extension
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Unilateral contraction – extension + sidebending
Latissimus dorsi
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Originates on Humerus
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Inserts on T7-12,Iliac crest, Thoracolumbar fascia
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Humerus motion and raises body to arms during climbing
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Innervation: Thoracodorsal nerve (C6-8)
Gluteus maximus
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Originates in Thoracolumbar fascia and on dorsal sacrum
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Inserts on Iliotibial band and femur
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Extends hip and stabilizes torso
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Innervation: Inferior Gluteal nerve (L5,S1-2)
Erector Spinae (L spine is part of their origin)  soft tissue techniques
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Large deep mm lying of each side of SP
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Iliocostalis, longissimus, spinalis
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Bilateral contraction-extension
Lecture 1 - Evaluation and Treatment of Lumbar Somatic Dysfunction
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Multifidus & Rotatores
o Smaller mm
o Deeper that erector spinae
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Unilateral contraction-extension +sidebending
control motion of individual vertebrae (Muscle Energy!)
Quadratus lumborum
o Attachments
 12th rib – functions with respiration
 Iliac crest
 Vertebral column
• Motion
o Bilateral contraction – extension
o Unilateral contraction – extension + sidebending
Don’t want to miss Cauda Equina syndrome, osteomyelitis
Emergency
spinal cord tumors with new onset paraplegia
epidural hemorrhage
epidural abscess
spinal artery thrombosis
Lecture 1 - Evaluation and Treatment of Lumbar Somatic Dysfunction
central herniation of nucleus pulposus
abdominal anuerysm
Chapman’s reflexes
bowel and bladder dysfunction
urinary stream decrease
IT bands
perineal pain
Stress
Possible GI Influence  erector spinae muscles
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Increased Sympathetics
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Ileus
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Constipation
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Abdominal pain
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Flatulence
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Distension
Increased Parasympathetics
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Colitis
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Crohn’s
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IBS (both inc.)
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Diarrhea
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Vomiting
Small unseen is adrenocortical ganglion
Viscerosomatic Considerations:
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Visceral disease can give palpatory findings in the lumbar spine  “Viscerosomatic Reflex”
Lecture 1 - Evaluation and Treatment of Lumbar Somatic Dysfunction
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T12-L2
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Left Colon, Bladder, Uterus/Ovaries, Prostate, Kidneys, Lower Extremity
Somatovisceral Considerations:
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SD of the Lumbar Spine can affect the sympathetic nervous system which can affect associated
organs.
Lecture 1 - Evaluation and Treatment of Lumbar Somatic Dysfunction
Fryette’s Principles of Physiologic Motion
1st Principle
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When sidebending is attempted from neutral (anatomical) position, rotation of vertebral
bodies follows to the opposite direction.
2nd Principle
Lecture 1 - Evaluation and Treatment of Lumbar Somatic Dysfunction
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When sidebending is attempted from non-neutral (hyperflexed or hyperextended) position,
rotation must precede sidebending to the same side.
3rd Principle
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Motion introduced in one plane limits and modifies motion in the other planes.
Coupled movements change in response to the position and the degree of flexion or extension of the
sagittal plane of the spine
Fryette’s Principal # I.
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I. When the spine is in a neutral position(easy normal) and sidebending is introduced, the bodies
of the vertebrae will rotate toward the convexity.
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In a neutral position, sidebending occurs 1st with rotation 2nd in the OPPOSITE direction.
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NSXRY
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“Neutral”  Point of balance of an articular surface from which all physiologic motions in that
articulation take place.
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“easy normal”- spine in a resting position.
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T-spine – “neutral range” occurs with FB.
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L-spine – “neutral range” occurs with BB.
“That range of forward bending(T spine) or backward bending(L spine) where the motion is not
dependent upon the facets but on the body of the vertebrae.”
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Fryette Type 1 & Type 2 Mechanics: Apply only to T and L spine!
All spinal and vertebral movements are described in relation to motions of their anterior and superior
surfaces
Lumbar facet orientation is relatively aligned in the sagittal plane. Thoracics align in coronal plane
(ribs limit thoracic motion)
Osteopathic notation:
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Type I Fryette’s Mechanics
Type I mechanics usually occur with groups of segments
Lecture 1 - Evaluation and Treatment of Lumbar Somatic Dysfunction
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o Greatest motion often occurs towards the middle segments
Neutral mechanics: sidebending PRECEEDS rotation
Osteopathic Notation follows the sequence of events:
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EXAMPLE: from a neutral position,
o First sidebending left occurs
o As it continues, right rotation must occur to accommodate the continued motion
Therefore: N SLRR
Writing a formula for vertebral motion with the spine in “neutral” position:
1. Position of sagittal plane: Neutral=“N”
2. Position of coronal plane: Sidebending=“SX”
3. Position of horizontal plane: Rotation=“RY”
NSXRY
Ex: L3 in neutral position(resting lordosis), sidebent left and rotated right (on L4, the segment below):
L3 NSLRR
Type I - Lumbar
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Sacrum: fused vertebral segments.
Neutral: Side bent Right, Rotated Left  L1-L5: NSRRL
• Sidebending of the lumber spine impinges on right oblique axis of the sacrum (always
named for upper pole)
• Ligamentous attachments create right rotation of the axis around this right oblique axis
(remember that motion is determined by a point on the superior anterior portion of the
moving body part) ((in this view we are looking from the posterior perspective)) FYI
only: this is noted R on ROA.
Fryette’s Principal # II
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II. When the spine is either forward bent or backward bent usually causing straightening of
the spine (“rigid rod”), and sidebending is introduced, rotation will occur into the concavity.
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In a non-neutral position(flexed or extended), rotation occurs 1st with sidebending following in
the same direction.
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Ex: ERXSX–what might occur in the T spine
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FRXSX-what might occur in the L spine
Lecture 1 - Evaluation and Treatment of Lumbar Somatic Dysfunction
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Non-neutral (Fryette Type II):
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“Motion occurring when the spine is in a position where facet structures determine the
motion characteristics.”
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Spine usually straightened(“rigid rod”)
Osteopathic notation:
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Type II Fryette’ Mechanics-apply only to the T & L spine!
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Usually occur as single segment dysfunctions
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Non -Neutral mechanics: rotation PRECEEDS sidebending
Osteopathic Notation follows the sequence of events:
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Applies only to T and L spine!
EXAMPLE: Therefore: F RLSL or E RLSL
Patient bends to end of flexion
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Attempts to reach “down and over”
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Rotation of one segment precedes sidebending to same side
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Sidebending of lumber spine impinges on upper sacral diagonal axis (here: left oblique
sacral axis has been set up)
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Soft and body constraints cause the sacrum to rotate (here: rotate to the left, remember
that orientation is a point on the anterior superior portion of the sacrum)
Physiologic motion becomes somatic dysfunction if the segments do not return to “normal” after
completion of motion. They may be pure sagittal plane dysfunctions, neutral dysfunctions, or flexed
or extended non neutral dysfunctions.