Osteopathic Manipulative Treatment (OMT) Workshop

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Osteopathic Manipulative Treatment (OMT) Workshop

• Sean N. Martin, DO
• Some Material Adapted, With Permission, From
  OMT for Allopaths Course by Shawn Kerger, DO

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What Does Osteopathy Mean?

• Comes from the Latin prefix of osteo, referring
  to bone and pathos, which later came to mean
  disease, but initially meant knowledge.
• It is this latter definition to which osteopathy
  was termed by Andrew Taylor Still, MD.

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4 Tenets of Osteopathic Philosophy

• The body is a unit.
• The body possesses self-regulatory, self-healing,
  and health maintenance mechanisms.
• Structure and function are reciprocally
  interrelated.
• Rational therapy is based on an understanding of
  body unity, self-regulatory mechanisms, and the
  interrelationship of structure and function.

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What It Is

• Todays Agenda, Were Going Lavorpa
• Combination of Didactic and Tactile Assimilation
  of Basic OMT Concepts Into The Cerebral Cortices
  of Providers with Moderately Advanced Knowledge
  of Musculoskeletal Anatomy
• In other words, a custom course built for Sports
  Medicine Fellows , Faculty, and Physical
  Therapists at Dewitt Army Community Hospital for
  Thursday Didactics

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What It Is Not

• Not on todays agenda
• History of OMT
• Spinal Mechanics/Dyfunction/Correction
• Sacral Mechanics/Dysfunction/Correction
• High Velocity Low Amplitude (HVLA) Techniques
• A Discourse on Evidence (or Lack Thereof) Behind
  This Field

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Disclaimers

• This is not a standardized field of medicine
• Learn a lot of techniques, get good at some,
  regularly use a few
• When in doubt, shotgun!!

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Plan

• Foundation Principles
• A Palpatory Warm Up
• Tissue/Myofascial
• Strain-Counterstrain
• Muscle Energy
• Approach to the Low Back Pain Patient

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Some guidelines

• Remember to explain what youre doing and why
  when treating a patient for the first time
• Hygiene
• Short, clean nails
• Hand-washing
• Your touch communicates as well as diagnoses and
  treats be careful what you say!
• Match the treatment to the problem

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Somatic dysfunctions Huh?

• T.A.R.T.
• Tenderness
• Asymmetry
• Range of Motion changes
• Tissue texture changes
• Like a syndrome not really defined, but
  described

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Somatic Dysfunction

• Impaired or altered function of related
  components of the somatic (body framework)
  system
• skeletal, arthrodial, and myofascial structures
• related vascular, lymphatic, and neural elements

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Palpation

• Information
• Tissue changes
• Will go more in depth in a moment
• Communication
• Patient
• Physician
• Treatment

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Palpation - Information

• Skin
• Temperature
• Fluid status
• Oily/dry measure of autonomous nervous tone
• Hyperesthesia

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Palpation - Information

• Muscular layers
• Tension / Spasticity
• Fresh injury
• Softer
• Hot
• Edematous
• Painful
• Old injury
• Hard
• Cold
• Ropy
• Sore

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Palpation - Information

• Trigger Points
• Usually located at or in muscular layers and
  reproduce a referred pain with pressure
• Tender Points
• As above without referred pain

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Palpation

• More of training your mind to listen to your
  hands.
• Try to identify the sides of a coin (heads/tails)
• Can you feel the date line? Try it with your
  eyes closed.
• Could you distinguish between a human bone and a
  solid plastic replica? How?

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Palpation Exercises

• Touch the dorsum of the other hand
• Test for temperature difference
• Skin Drag
• Calluses on palmar aspect
• Veins vs. arteries vs. tendons
• Check before and after squeezing your hand firmly
  several times
• Shear stress in subcutaneous tissues

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Palpation Exercises

• Palpate Partners Forearm
• Compare skin differences of volar and dorsal
  aspects (which is smoother, thicker, warmer, or
  drier?)
• SubQ fascial layer just below the skin. How
  thick, plastic, loose? In which directions are
  ease vs. drag?
• Deep fascia is next layer down. Can you identify
  / separate the different muscle bundles of the
  forearm?

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Palpation Exercises

• Palpate Partners Forearm
• How does the underlying muscle feel? Tight?
  Soft? Strained?
• Have your partner open/close the hand slowly,
  then with more and more force. With sustained
  force, this muscle is what muscles feel like when
  associated with a somatic dysfunction.

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Palpation Exercises

• Palpate Partners Forearm
• Move your hand down slowly toward the
  musculotendinous junction. Then move past this
  to the tendons notice the change as it becomes
  tendon.
• Follow the tendons as they mesh with the
  transverse carpal ligament and palmar carpal
  ligament notice the fiber direction!

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Soft Tissue/Myofascial
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Soft Tissue

• Can be classified as direct or indirect
• Addresses the muscular and fascial structures of
  the body with their associated neural and
  vascular elements (especially lymphatics)
• Most of us have applied these techniques to a
  friend or family member, but not a patient!

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Soft Tissue

• Relaxes hypertonic muscles
• Stretches passive fascial structures
• Enhances circulation
• Improves local tissue nutrition, oxygenation, and
  removal of metabolic wastes

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Soft Tissue

• Improves local systemic
• immune responsiveness

• Identifies areas of somatic dysfunction
• Observes tissue response to application of
  manipulative technique
• Improves abnormal somatosomatic and
  somatovisceral reflex activity

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Soft Tissue

• Provides a general state of relaxation
• Provides a general state of tonic stimulation
• Way of introducing confidence with a new patient
• Evaluate patients response to physical contact

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Soft Tissue

• Various applications
• Rapid, short massage maneuvers (like a boxer
  before the fight)
• Long, slow stretches
• Longitudinal to fibers
• Perpendicular to fibers

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Soft Tissue

• Tractional technique
• Stretching
• Origin and insertion of a myofascial structure is
  separated longitudinally
• Can be both therapeutic and diagnostic

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Soft Tissue

• Kneading
• A rhythmic, lateral stretching of a myofascial
  structure, in which the origin and insertion are
  held stationary and the central portion is
  stretched like a bowstring

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Soft Tissue

• Inhibition
• Sustained deep pressure over a hypertonic
  myofascial structure
• Can be gentleor not!!

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Thoracic Prone Traction

• Anatomy

• Great for
• Kyphosis
• General massage
• Prep for HVLA
• Treat hypertonicity of thoracic visceral disease
  (asthma, COPD, HTN, CAD)

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Thoracic Prone Traction

• Pt Prone
• Place thumbs of both hands just lateral to the
  spinous processes, on the paravertebral muscles,
  with your fingers fanned out. Dont lock out
  elbows!
• Exert an anterior pressure, allowing muscle to
  relax and stretch, finishing with a lateral
  sweeping motion
• A kneading motion or inhibitory pressure may also
  be used
• Repeat as needed

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Lumbar Prone Traction

• Anatomy
• Great for
• Low back pain
• Lumbago
• Rotated pelvis
• Prep for another technique
• General starting technique
• Treat pelvis and abdominal viscerosomatic tone
  (constipation, dysmenorrhea, IBS, hemorrhoids,
  etc)

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Lumbar Prone Traction

• Pt prone

• Use the heel of your cephalad hand to contact
  the opposite paravertebral musculature

• Gently grasp the ASIS with your caudad hand and
  pull upward, inducing rotation

• Apply a counterforce with your cephalad hand
• May use a kneading motion, or deep inhibitory
  pressure
• Repeat as needed

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Strain-Counterstrain
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Strain-Counterstrain

• Developed by Lawrence H. Jones, DO, FAAO in 1955
• relieving spinal or other joint pain by
  passively putting the joint into its position of
  greatest comfort.
• Relieving pain by reduction and arrest of the
  continuing inappropriate proprioceptor activity.

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Strain-Counterstrain

• Works utilizing the neuroanatomy and
  neurophysiology of the gamma efferent loop
• Involves the gamma efferent fibers, the
  intrafusal fibers, the alpha motor neurons, and
  the small anterior horn cells which terminate on
  the intrafusal muscle fibers within the spindles.

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Gamma Loop

• Tendon stretches the spindle muscle fibers
• This activates the afferent nerve fibers which
  synapse in the anterior horn (Im skipping the
  numerous interneurons for simplicity) on the
  alpha motor neurons in the same and adjacent
  spinal segments, simultaneously inhibiting the
  antagonists.

()
(-)
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Strain-Counterstrain

• Find the specific tender point (TP)
• Place the patient in the position of optimal
  comfort (POC)
• Maintain the POC for 90 seconds
• Slowly ( passively on the patients part) return
  to neutral position
• Recheck

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Strain-Counterstrain

• Key points
• Find the MOST painful tender point (TP) and treat
  that one first
• You (the doc) need to be comfortable and
  supported
• Go for 90 improvement in TP
• Wait at least 90 seconds
• These four tips will greatly improve your success
  rate!!

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Suboccipital Release

• Anatomy

• Great for
• MT headaches
• Sinus congestion
• Upper cervical pain
• Opening technique
• Stress relief
• Pt can do at home safely with two tennis
  balls taped together or tied off in the end of an
  athletic sock

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Suboccipital Release

• Suboccipital Release
• Pt. Supine
• Place the pads of your fingers just inferior to
  the superior nuchal line in the suboccipital
  muscles.
• Lift the head so that the pts weight is
  supported on the pads of your fingers (not the
  palms!)
• Maintain position until you feel the desired
  relaxation in the soft tissues

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3 Examples of Techniques Commonly Employed in
Sports Medicine
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Levator Scapula Strain

• Pt prone with head turned away
• Internally rotate arm and apply LARGE amount of
  traction
• Fine tune with degrees of extension, adduction
  and abduction
• Hold for 90 secs
• Return patient passively and slowly to neutral
  position

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Lateral Epicondylitis

• Better for subacute injuries/shorter duration of
  symptoms
• Extension at the wrist with a mild amount of
  valgus positioning with lesser degrees of
  internal or external rotation (although external
  rotation is more frequently necessary)
• Hold for 90 secs
• Return patient passively and slowly to neutral
  position

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Rhomboid lesion

• Tender point above T6
• Externally rotate the humerus at 90 degrees
  abduction and hold for 90 seconds
• May need a little more compression, distraction,
  abduction or adduction through the glenohumeral
  joint
• Return patient passively and slowly to neutral
  position

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Muscle Energy
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Active range of motion
Physiologic barrier
Anatomic barrier
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Motion Loss
Active range of motion
Pathologic barrier
Physiologic barrier
Anatomic barrier
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Shift of midline
Active range of motion
Pathologic barrier
Loss of motion
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Muscle Energy

• Utilize the patients active cooperation to
  correct a dysfunction
• Cannot be used in
• Too young
• Uncooperative
• Unconscious
• Fresh muscular injury
• Relatively contraindicated in low vitality
  patients who might be compromised by muscular
  exertion
• Postop
• Post-MI

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Muscle Energy

• Works via reestablishing a new tone in the
  slow-twitch/tonic musculature via the ?-efferent
  and extrafusal fiber systems.
• This is why you dont need to use too much force
  the slow-twitch fibers are earlier in the
  recruitment selection. Too much force and youll
  reset the wrong motor units.

()
(-)
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Muscle Energy

• Engage barrier
• Isometric contraction in opposite direction with
  3-5 of force for 5-7 seconds
• Relax for 2-3 seconds
• Move to new barrier
• Repeat until finished!

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Pelvic Exam
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Standing flexion test

• Pt is standing
• Place your hands on the iliac crests bilaterally,
  and your thumbs should fall right into the area
  of the PSIS. Move your thumbs to the inferior
  notch of the PSIS
• As patient bends forward, monitor thumbs
  whichever side moves cephalad first (and usually
  the farthest) is dysfunctional.

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Seated flexion test

• Pt is seated, with feet flat on floor, knees
  spread a bit, so hands can pass freely in middle.
• Place hands as in standing flexion test, pt bends
  forward at waist.
• Interpretation of results same as in standing
  flexion test.

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Functional Biomechanical Exam

• Tests of Pelvic Dysfunction
• Tests functioning of pelvis
• Standing / Seated Flexion Test
• () Standing FT (StFT) iliosacral dysfunction.
  Address Pelvis first.
• () Seated FT (SeFT) sacroiliac dysfunction.
  Address Sacrum first.
• (-) StFT / SeFT either no dysfunction or
  bilateral lesion (extremely rare)

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Hip Drop Test Lumbar

• Pt is standing
• Hands are on top of iliac crests, parallel to
  floor. Note starting position of hands.
• Pt bends one knee without lifting heel. Do not
  allow rotation or flexion/extension!
• Positive hip drop
• drop of less than 20-25
• a flat lumbar curve
• a rough, uneven lumbar curve

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Supine Examination

• Leg, Hip, and Pelvis Asymmetry
• Talus/Subtalar joint
• Medial malleoli
• Tibial tuberosities
• ASIS
• Pubic Symphysis
• Int/Ext ROM at hip
• Costal Cage Motion

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Anterior Innominate Rotations

• Pull of musculature is such that one hemipelvis
  is rotated anteriorly and is resistant to
  posterior motion, especially rotation. Usually
  due to tight hip flexors ipsilaterally.
• Findings
• ASIS is inferior PSIS is superior on
  ipsilateral side, but rami are symmetric
• () StFT, (-) SeFT on ipsilateral side

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Anterior Innominate Rotations
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Posterior Innominate Rotations

• Pull of musculature is such that one hemipelvis
  is rotated posteriorly and is resistant to
  anterior motion, especially rotation. Usually
  due to hypertonic hip extensors ipsilaterally.
• Findings
• ASIS is superior PSIS is inferior on
  ipsilateral side, but rami are symmetric
• () StFT, (-) SeFT on ipsilateral side

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Posterior Innominate Rotations
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Inferior Pubic Shears

• Pull of musculature is such that one hemipelvis
  is rotated anteriorly and is resistant to
  posterior motion. Usually due to tight hip
  flexors ipsilaterally prior to an injury. Often
  recalcitrant to OMT d/t improper Dx.
• Findings
• ASIS is inferior, PSIS is superior, and pubic
  ramus is inferior on ipsilateral side,
• () StFT, (-) SeFT on ipsilateral side

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Inferior Pubic Shears
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Superior Pubic Shears

• Pull of musculature is such that one hemipelvis
  is rotated posteriorly and is resistant to
  anterior motion. Usually due to tight hip
  extensors ipsilaterally prior to an injury. Often
  recalcitrant to OMT d/t improper Dx.
• Findings
• ASIS is superior, PSIS is inferior, and pubic
  ramus is superior on ipsilateral side.
• () StFT, (-) SeFT on ipsilateral side

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Superior Pubic Shears
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Inflared Innominate

• Pull of musculature is such that one hemipelvis
  is rotated medially and is resistant to lateral
  motion. Usually due to tight hip flexors and
  adductors ipsilaterally.
• Findings
• ASIS is medial on ipsilateral side, but rami and
  PSIS are symmetric.
• Umbilicus-ASIS distance is shorter on ipsilateral
  side.
• () StFT, (-) SeFT on ipsilateral side

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Outflared Innominate

• Pull of musculature is such that one hemipelvis
  is rotated laterally and is resistant to medial
  motion. Usually due to tight hip extensors and
  abductors ipsilaterally.
• Findings
• ASIS is lateral on ipsilateral side, but rami and
  PSIS are symmetric.
• Umbilicus-ASIS distance is longer on ipsilateral
  side.
• () StFT, (-) SeFT on ipsilateral side

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Upslipped Innominates

• Unusual dysfunction. Usually due to trauma in an
  upward fashion on an unsupported pelvis like
  stepping into a hole or off a curb unknowingly.
• Findings
• ASIS, PSIS, and pubic rami are superior on
  ipsilateral side.
• () StFT, (-) SeFT on ipsilateral side
• May be confused with an anatomically short leg.

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Downslipped Innominates

• Extremely rare dysfunction. Usually due to
  trauma in a downward fashion on an unsupported
  pelvis like falling off a horse with foot
  trapped in stirrup.
• Findings
• ASIS, PSIS, and pubic rami are inferior on
  ipsilateral side.
• () StFT, (-) SeFT on ipsilateral side
• May be confused with an anatomically long leg.

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Anterior Innominate Rotations

• Dx - () StFT on same side as Ant/Inf ASIS,
  Sup/Ant PSIS. Pubes stable. (-) SeFT.
• Tx
• Pt supine with ipsilateral knee hip flexed as
  far as comfortable.
• Pt then extends hip isometrically with 3-5 of
  force for 5-7 seconds.
• Relax for 1 second
• Take up the newly created slack to flexion and
  repeat.
• Recheck!

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Posterior Innominate Rotations

• Dx - () StFT on same side as Sup/Post ASIS,
  Post/Inf PSIS. Pubes stable. (-) SeFT.
• Tx - Pt supine w/ ipsil. leg hanging off table
  and hip extended as far as comfortable.
• Pt then flexes hip isometrically with 3-5 of
  force for 5-7 seconds.
• Relax for 1 second
• Take up the newly created slack to extension
  and repeat.
• Recheck

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Superior and Inferior Pubic Shears

• Dx - () StFT on affected side with uneven pubic
  rami (sup/ant or inf/post)
• Tx - Symphysis spread technique
• Pt is supine with bent knees adducted and hips
  ext flexed.
• Isometric abduction contraction of 5-10 of
  pressure is maintained for 5-7 seconds.
• Proceed to part two. May be repeated if needed.

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Superior and Inferior Pubic Shears

• Dx - () StFT on affected side with uneven pubic
  rami (sup/ant or inf/post)
• Tx - Symphysis spread technique
• pt is supine with bent knees abducted and hips
  flexed and ext rotated.
• Isometric contraction of 3-5 of pressure is
  maintained for 5-7 seconds.
• Recheck and repeat as needed.

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Approach To Treatment of the Low Back Pain Patient

• Step 1- Prone Traction
• Step 2- Correct any Innominate Anomalies
• Step 3- Shotgun Pubic Symphysis
• Step 4- Muscle Energy/Traction To Lower Lumbar
  Spine and/or SI Joint
• Step 5- Lumbar Roll
• Step 6- Strain-Counterstrain To Any Tenderpoints

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Miscellaneous Techniques
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Piriformis lesion

• Dx - () TTP over piriformis () SeFT on
  affected side. (/-) Sciatic Sx.
• Tx
• Pt supine and LE flexed to 90º, then taken to
  end-ROM in external rotation
• Iometric contraction toward external rotation
  with 3-5 of pressure is maintained for 5-7
  seconds.
• Relax for 1 second
• Take up the newly created slack to internal
  rotation and repeat as needed.
• Recheck.

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Obturator lesion

• Dx - () TTP over muscle (inf. to piriformis).
  Decreased internal or rotation c/w contralateral
  LE.
• Tx
• Pt prone and LE taken to end-ROM into internal
  rotation..
• Isometric contraction of 3-5 of pressure is
  maintained for 5-7 seconds in opposite direction.
• Relax for 1 second.
• Take up the newly created slack to extension
  and repeat.
• Recheck.

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Thank You for Your Participation