27th Annual SW Conference on Medicine

Westin La Paloma SpaTucson

April 27-29

Edward G. Stiles, DO, FAAODist.Professor of OPP

Kentucky College of Osteopathic Medicine

Sturgill Distinguished ProfessorUniversity of Pikeville

Workshop: OMT principles & care

Sponsors:

• Tucson Osteopathic Medical Foundation

• Cleveland Clinic

Challenges for this workshop: Diversity of participants

• DOs: improve OPP knowledge & OMT skills• MDs: provide / improve OPP knowledge & skills

• NP: make aware of OPP potential• PA: make aware of OPP potential

• DO students: improve skills

Goals:

enable all to gain new OPP understanding and OMT skills

Greenman:

•“ the expert is the one who does the basics the best”•“what makes a DO different is not OMT,

but how they think / problem solve.”•Dispelling some OMT myths

• Something is not “out of place”: it can’t completely open or close.

• Your not “putting something back in place” but restoring physiological motion, doesn’t require a lot of force.

• OMT is not a panacea but can be dramatic when S/D is a major etiological component.

• One indication for OMT ! presence of somatic dysfunction ( S/D ) - not pain, muscle guarding, etc.

• Osteopathic Joint model: vs “out of place” model

Pardigm shifts:

• Amount of force utilized with OMT: Mitchell stool demonstration

• Stiles’ musculo-skeletal / mesokinetic model: Tensegrity• Need to find AGR / sequence: least healthy / functional area

•“Learn principles and get them to work for you”: Kimberly• Spinal mechanics: facet model

• Direct techniques• Demo the facet model for Dx and Rx ( thoracic, cervical & lumbar )

• Using translation to Dx and Rx: the KEY !• HV/LA thumb thrust ( Osteopathic Activator ) – Thoracic

• MET: using a patient specific muscle corrective force• T6-11 FRS dysfunctions MET ( 2 steps )• T12 FRS dysfunctions MET ( 2 steps )

• Indirect techniques ( Laughlin - Still ) thoracic, cervical & lumbar

• Sacral complexity: Left sacral Flexion ( use as example )

• Innominate: “fine-tuning”/ activating only prime mover• Ribs: basic Dx and Rx

Joint Mechanics:an

Osteopathic Perspective

( Normal and abnormal - somatic dysfunction )

What is Somatic dysfunction ?

( S/D )

Normal Joint Mechanics

A E P AEP

Active ROM

Passive ROM

• Elastic & Physiological barriers: provide support & movement• Hypermobility issue: hindered elastic barrier

• Workman’s Compensation: hypomobility significance

Normal & Dysfunctional Joint Mechanics

A E P AEPA = anatomical barrier: bony shape of the joint ( hip / shoulder ) FX / dislocation

E = elastic barrier: ligaments & capsules / dislocations possibleP = physiological barrier: myofascial tissues

Active ROM: between the physiological barriers / restrictive barrierPassive ROM: between the elastic barriers / restrictive barrier

N = neutral: position of easeDBP = dynamic balance point: dysfunctional position of ease

R = Restrictive Barrier: “not out of place” / minimal, moderate, marked, etc.Damaged E. Barrier can account for hypermobility ( Tensegrity / prolo therapy )

R. Barrier will decrease Range of Motion ( O.M.T. )Nothing is out of place ! But functionally disorientated !

GOAL OF O.M.T.: not to put something back in place

but to re-establish normal range of motion. Remove the functional hindrances.

NDBP

Active ROM

Passive ROM

CONSILIENCE:• E. O. WILSON PhD: HARVARD BIOLOGIST

• A “CALL FOR A UNITY OF ALL KNOWLEDGE”

NATURAL SYSTEMS ARE RESILIENT

UNTIL WE INTRODUCE MECHANISTIC INTERFACES –WITH ALL THE NECESSARY

ADJUSTMENTS AND COMPENSATIONS –AS A MEANS OF SUSTAINING OURSELVES.

THOSE INTERFACES NOT ONLY ISOLATE US FROM NATURE

BUT AT THE SAME TIME CREATE SYSTEMS

THAT AREBRITTLE AND DELICATE

• LOWERED RESISTANCE ?• INCREASED SUSCEPTIBLITY ?

• BECOME LESS NON-LINEAR ! FRAGILE• BECOME “DIS-EASED” HOST

A HARVARD DESCRIPTION OF Somatic Dysfucntion –H IMPACT ?

NOTE: EXCHANGE THE WORDS HOST AND S/D-H

Paradigm Shift:2018

looking at familiar data, come to new understanding &new way of explaining old observations

“Learn the principles and get themto work for you.”

Paul E. Kimberly, DO, FAAO

• Anatomical design• OMT mechanisms

The Musculo-Skeletal System

a21st. Century Perspective

Tensegrity structures are:•Light weight

•Much stronger than experts had predicted•Multi / Omni - directional

•Whole system adapts to stressors•Protects the “weakest link” / the A.G.R.

• defy gravity•Non-metallic materials, organized in a

Tensegrity arrangement, can conduct electricity

• ‘wired’: keep eyes level, evenly distributeweight among all 4 quadrants.•Conduct vibratory information

•Would it not make sense to identify, the A.G.R.

( area of greatest restriction - hindrance )

in thisflexible & adaptive system ?

MESOKINETIC SYSTEMMeso ( mesoderm ): gives rise to

•Connective tissues & fascia•Cartilage

•Bone•Striated and smooth muscle

•Myocardium and pericardium•Blood and lymph vessels

•Kidneys and ureters•Adrenal cortex

•Gonads•Tubes, uterus and upper vagina

•Serous membranes lining the body cavities ( T, A & P )•GI fascial support system

•Spleen

Kinetic:Related to movement of physical objects

NOTE:S/D might impact both musculo-skeletal & visceral structures.

Netter’s Atlas of Human Embryology 16

MESOKINETIC SYSTEMMeso ( mesoderm ): gives rise to

•Connective tissues & fascia•Cartilage

•Bone•Striated and smooth muscle

•Myocardium and pericardium•Blood and lymph vessels

•Kidneys and ureters•Adrenal cortex

•Gonads•Tubes, uterus and upper vagina

•Serous membranes lining the body cavities ( T, A & P )•GI fascial support system

•Spleen

Kinetic:Related to movement of physical objects

NOTE:S/D might impact both mysculo-skeletal & visceral structures.

Netter’s Atlas of Human Embryology 16

Passing on the TraditionAlan Becker, DO, FAAO 2010Journal of AAO – fall edition

•“Dr. Still was keen on being very specific.•He looked at the patient as a Totality.

•He looked for the Elusive Key Lesion – Hindrance ( somatic dysfunction )

that people have quoted for years”.

•That is what He looked for and

when He found it, He fixed it and then left it alone.He said that once done,

the body will do its own work because it is designed to do its own work.

•Our job is to find the Key Restriction – Hindranceto

homeostatic integrity,and once restored to normalcy,

to rest assured that the body will take care of the rest of the work”.

LBP patientA.G.R.

( Key somatic dysfunction )

( Stiles: 100 patients )• T/RC = 60%

• Lumbar = 24%• L.E. = 11%Total: 95%

Note:Sacrum

andinnominates were not the #1 A.G.R. !

may have been treated later in the

treatment sequence

L.B.P.

Other possible A.G.R.s•Cranial: dural tube

•U.E.•L.E.

•Note: ever see a LBP research strategy which considered S/D

in T/RC, UE, LE or cranial ?

In light of this complexity,how do you clinically view your patients ?

Stiles’ Current Perspectivecomplex, dynamic,

inter-connected & inter-woven,multiple, simultaneously functioning systems,

non-linear,autopoietic

functional unit

OPP treatment basic principles: 2 technique components

Positioning of S/D: re Restrictive Barrier• Direct:

• HV/LA: Kimberly,” should be painless and noiseless”( avoid trap of a hypermobile “pop” )

• Muscle Energy• Myofascial

• Indirect:• Strain-Counterstrain ( S/CS )• Balanced Ligamentous Tension ( BLT )• Facilitated Positional Release ( FPR )• Still Techniques ( ST )• Functional / Laughlin ( FRT/L )

Corrective Force:• Clinician introduced force: a thrust / an impulse• Patient introduced force: patient specific muscle effort• Intrinsic forces: self-healing forces of body

Tell me aboutFred L. Mitchell, Sr, DO, FAAO

• Mechanical Engineer• Creative Thinker

• Non-linear Thinker• Tensegrity “thinker”• utilized Cybernetics

• Complex Adaptive Systems Thinker• Phenomenologist

•These attributes enabled Fred to develop:• the unique Mitchell Pelvic Axis Model

• plus a totally new OMT approach utilizing a

patient generated corrective force.• stressed the importance of starting your treatment

at the Key S/D of the total system.

4 Tutorial participants: Greenman, Stiles, Sutton, & Ward are Legends being honored during 2018 Convocation.

Picture = 1,000 words

MSU-COM1972

Leon Chaitow, DO

Comments about various techniques in light of data presentedduring the 4th Fascia Congress: ( Sept. 2015 )

Muscle Energy Techniques• “It is not a Post Isometric Relaxation technique ( PIR ) ! ”

• M.E.T. introduce movement which then decreases the pain.• Leon felt my hypothesis that introduced movement

stimulates the joint mechano-receptors and that

inhibits the nociceptors was an appropriate expanded explanation of his statement.

( Wyke 1980’s research . . . 10+ yrs. after 1st M.E.T. Tutorial ) 48

MUSCLE ENERGY TECHNIQUES( MUSCLE ACTIVATION )

SUMMARY

8 ESSENTIALS: also explains why it doesn't work

• ACCURATE DIAGNOSIS• A.G.R. / SEQUENCING . . . Crucial for FLM,Sr.• SEGMENTAL DIAGNOSIS . . . Specific OMT

• ACCURATE POSITIONING• “FEATHER EDGE” OF RESTRICTIVE BARRIER . . . crucial• DIRECT – BALANCED LIGAMENTOUS TENSION

• UNYIELDING COUNTER-FORCE . . . Crucial( FUNCTIONALLY REVERSES THE ORIGIN AND INSERTION )

• APPROPRIATE MUSCLE EFFORT• DIRECTION: multiple options ( Findley )• AMOUNT: least amount that produces beneficial change• DURATION . . . Cybernetic loop key

• COMPLETE RELAXATION @ Rx SITE BUT DON’T GIVE UP WHAT GAINED

• REPEAT ABOVE STEPS . . . remaining R. barrier, not new ! , # efforts ?• RE-TEST . . . Taking money under false pretenses ?, confirms Dx / Rx

21

A.A.O.M.E.T. - 3 VISIONS

M.E.T. – 3 MASTERSFRED, ED & PHIL SHOW

2005

Functional: Laughlin-Still basics

• establish a S/D diagnosis( works best if start at A.G.R.-H / Key “lesion” )

• start technique at Positional Diagnosis position( take “doodad where it wants to go” )

( “position of ease” )( use translation & have at apex of F/E, SB & R curves )• “fine-tune” dysfunctional joint so maximally relaxed

( “fiddle and diddle” to “fine-tune positioning at D.B.P.” )( Dynamic Balance Point )

Biodynamics language: at “loose-packed” position• add vectored compression

( from side towards which dysfunction will initially rotate )• allow to “unwind”

( initially away from restricted barrier, hits a ‘still point’ & then spontaneously moves into the previously restricted compartment )

• recheck: know made a positive change !2

POSITIONING:FUNCTIONAL TECHNIQUES

• SINCE AN INDIRECT TECHNIQUE• POSITION AT D.B.P.

WHICH IS IN THE ‘POSITIONAL DIAGNOSIS QUADRANT ‘

( NOT AT JOINT NEUTRAL BUT AT JOINT ‘S/D-H’ NEUTRAL )

• EX: DIAGNOSIS L3 FRSL• THE D.B.P.

WILL BE IN THE FRSL QUADRANT

A E P AEP

NDBPFLEXION EXTENSION

R.B.

FUNCTIONAL TECHNIQUES: ALL START AT THE ‘SAME’ POINT / DIFF. NAMES

• IF MONITOR THE DYSFUNCTIONAL FACET & TISSUE CHANGES ( FRT/L-Stiles )[ MECHANORECEPTOR / NOCICEPTOR ROLE WITH PASSIVE ‘UNWINDING’ ]

• IF MONITOR LIGAMENTOUS TENSION ( BLT – WALES, LIPPINCOTT, BECKER & SUTHERLAND )• IF MONITOR A JONES TENDER POINT ( S/CS – JONES )

• IF MONITOR SUPERFICIAL OR DEEP MUSCLES ( FPR – SHIOWITZ )• IF MONITOR 3 SEGMENTS ( FUNCTIONAL METHODS – JOHNSTON )

• IF ACTIVELY BRING THROUGH RESTRICTIVE BARRIER ( STILL – VAN BUSKIRK )( MISINTERPRETED A.T. STILL / SHOULDER VIDEO ? ) 23

“The

scientific method of phenomenology ( Goethean Scientific Method )is used to create a synthesis

between modern orthodox embryology

and a holistic view of the human being.

The human embryo reveals who we are and what we are meant to be.

Practitioners have found that comprehending embryological forces

supports a holistic and biodynamic approach to healthcare because the same forces that formed the body are

continuously at work throughout life,

carrying the blueprint of health into manifestation.”Jaap van der Waal, MD, PhD

The Embryo in UsMay 19-22 2016

A.T. Still: find S/D hindrances, effectively treat the S/D hindrances and enable the “blueprint of health” to emerge / to manifest.Forces we are tapping into by removing S/D hindrances.

Note:I am not saying

AGR / sequencing is the only way

to approach patients !

but

our data suggests

it is an effective clinical strategy

Stiles’ Data: methods• Spinoscope / Gracovetsky

• sEMG evaluation• Ground Reactive Force

• Fractal Analysis• Reactive Fractal Analysis

• golfers• Elite female runners

• Dynamic Athletic Research Institute( DARI ) Jason Hunt, DO - orthopod

Sequenced OMT

Median of 60 gait cycles( tons of data )

• Statistical & fractal significant changes• Immediate changes with sequenced OMT,

not with models, chasing pain or exercise.• Each patient their own research project

Ground Reactive Force data:See similar changes 80% of time with new patients

Not saying AGR / sequencing right way

and other strategies are wrong,just saying we have a lot of data to

support the AGR / sequencing strategy

utilizing several data collection strategies

Spinal Mechanicsan

Osteopathic Perspective

SpinalMechanics

Bottomline

Type I Mechanics:•Bodies in control•Involves multiple vertebra•SB / R occur in

opposite directions•Rotation is toward

produced convexity•Compensate for Type II, pelvic

or rib cage dysfunctions

Type II Mechanics:•Facets in control•Involves 2 vertebra•SB / R occur in the

same direction•R toward produced concavity•Associated with segmental

facilitation

Act likea

pile of

blocks

act like flexible

ruler

Key to establishing an

accurate diagnosis and

quality localizationof your treatment forces

TRANSLATION •Moving a segment along a line

( introduces forces from both above and below )

•Have the segment being diagnosed ! ! !

and

treated ! ! !“floating” at the apex of the curve . . . integrates

( using Law III of Fryette’s Principles to your advantage )

•Minimal dysfunctions can be missed when use just flexion, extension, SBR, SBL or RR, RL

( forces introduced from only above . . . segment not at apex ) 29

XX

Spinal Mechanics: Type II palpate over facets

Flexion

Extension

X

X

ERSL( can’tgo intoFlexionon left )

FRSL( Can’t go into Extensionon right )

Note: both are SBL and RLNeed to use both flexion & extension

to establish an accurate diagnosis

Long mobilizers / restrictors

Short mobilizers / restrictors

DIAGNOSIS:ERSL

Rx – M.E.T.

UnyieldingCounter Force

Treatment procedure:•Position FRSR against “feather edge” of R. Barrier ( D-BLT )

•Do this using translation in 3 planes•Dysfunctional facet pair within normal range of motion

•“fiddle and diddle” to fine tune to dysfunctional facet pair ( left )•Patient makes a gentle isometric SBL and / or RL, or both muscle effort against

a gentle unyielding counter force !•2 effects occur

• Inhibits short restrictors ( Golgi receptor / protective role activated ): inhibited, not stretched !• Long mobilizers restore some of the lost movement ( micro-isotonic response )

• Facet mechano-receptors stimulated and inhibit the pain receptors ( Wyke )•Hold until “cybernetic feedback loop” displays movement, L. facets pair opens

•Have patient relax the treated area•Reposition against the remaining / not new R. Barrier: “take up the slack”

•Repeat 2-3 times• not Post Isometric Relaxation technique

Long mobilizers / restrictors

Short mobilizers / restrictors( “timing gear” problem )

DIAGNOSIS:FRSL

Rx - M.E.T.

UnyieldingCounter Force

Treatment procedure:•Position ERSR against “feather edge” of R. Barrier ( D-BLT )

•Do this using translation in 3 planes•Dysfunctional facet pair within normal range of motion

•“fiddle and diddle” to fine tune to dysfunctional facet pair ( right )•Patient makes a gentle isometric SBL and / or RL, or both muscle effort against

a gentle unyielding counter force !•2 effects occur

• Using the left long mobilizers activates the law of reciprocal innervation, inhibits contralateral short restrictors . . . Doesn’t stretch short restrictors, inhibits them. • Then long mobilizers restore some of the lost movement ( micro-isotonic response )• As closes, stimulates mechano-receptors which then inhibit pain receptors. ( Wyke )

•Hold until “cybernetic feedback loop” displays movement . . . SBR &RR closes R. facet pair•Have patient relax the treated area

•Reposition against the remaining / not new R. Barrier: “take up the slack”•Repeat 2-3 times

• not Post Isometric Relaxation technique

X

CNS RESPONSE: A “VIRUS” IN THE

SOFT-WARE PROGRAM OF THE C.N.S.

( AN ANALOGY )

DYSFUNCTIONS PLUS

ADAPTIVEPATTERNS

ARE PRESENT IN THE MESOKINETIC SYSTEM

BUT

MAINTAINED IN THE C.N.S. ?

NEUROPHYSIOLOGICAL ROLE Our Eugene & Golf data support

this concept 33

X

X

OKC 1994Bob Foreman, PhD

Ch: Physiology OUMed

AFTER 2008: Engineering Biomechanics of Human Motion

Robert L. Williams, PhD Ohio Universitywillar4@ohio.edu

“virusin

software”analogy

• S/D-H pattern maintained in cerebellum ?

• Cerebellum enables total body adaptations

to occur to:• Keep eyes level

• Evenly distribute weight in all 4 quadrants

• Why finding KEY is important !• Treating Pr. or Sec. S/D ?

T7 ERSL : Functional

Position: instruct patient to•Sit up and push stomach forward

•You then translate T7/8 area to right•These 2 movements “close” the

left facet pair( taking “doodad where wants to go” )

( “fiddle & diddle” to fine tune & add rotation )•Add vectored compression toward

dysfunctional facet pair•Allow to “unwind” in both directions

• maintain compression during whole treatment• ends up at FRSR, may be neutral.

•Recheck: realize self healing potential

6Palpatewhere ?

T7 FRSL Functional

Positioning: instruct patient to•Slump forward / apex of F/E curve

•You then add translation T7/8 to right so at apex of both flexion & SBL curves.

•These 2 movements “open” the right facet pair

( taking “doodad where it wants to go “ )( “fiddle & diddle” to fine tune & add R )

•Add vectored compression toward dysfunctional facet pair

•Allow to “unwind” in both directions•Maintain compression throughout treatment• usually ends up at ERSR, or may be neutral.

7

Palpatewhere ?

LUMBAR DYSFUNCTION: L3 FRSL Functional

POSITION:L3 FRSL

USING TRANSLATION‘FLOAT’ R. FACET PAIR

LOAD OR BEAR WEIGHT

ON

L. I/T

FASCIAL LOAD

TOWARD R. FACET PAIR

37

AS SLOWLY ADD

COMPRESSIONTOWARD

RIGHTFACET PAIR,

THE BODY WILL AUTOMATICALLY

• ROTATE LEFT• HIT A “STILL POINT”

• THEN SPONTANEOUSLY

ROTATESTO RIGHT TOWARD

“RESOLVED”RESTRICTED

BARRIER

ESSENTIALS:• ANT. LUMBAR IS‘LOOKING’ LEFT( SIDE LOAD I.T. )

• RIGHT FACET PR. ISDYSFUNCTIONAL

( SIDE FLOAT )

CervicalRegion

During extension: using fingertip translation, facets should close.If facets don’t close, test both sides for resistance using diagonal translation.

During flexion: using lateral translation, facets should open,test both sides for resistance

Treatment: either • direct ( MET or HV/LA)• indirect: at “position of ease”

FUNCTIONAL TECHNIQUEScervical area

SCREENING EXAMINATION PATIENT IS SEATEDOPERATOR STANDS NEXT TO THE PATIENT

WITH ONE HAND ON THE PATIENT’S HEAD THE OTHER HAND PALPATES ALONG THE

ARTICULAR COLUMN UTILIZING THE DISTAL PAD THE THUMB ( OVER THE FACETS )

• THUMB SLIDES CEPHLAD OVER ARTICULAR COLUMN • AS THE NECK IS ROTATED . . . USE COMPRESSION

• LOOK FOR ‘SPEED-BUMPS’

• PASSIVELY Dx . . . FINDING D.B.P. / POSITION OF EASE 39

FUNCTIONAL TECHNIQUESlower cervical area

40

DIAGNOSIS: FRSR• PATIENT IS SITTING• PASSIVELY POSITION THE

DYSFUNCTIONAL VERTEBRA @ DBP OF FRSR THEN “FIDDLE & DIDDLE” TO “FINE-TUNE”

• ADD GENTLE CAUDAD COMPRESSION TOWARD SEGMENT ( DYSFUNCTIONAL FACET PAIR )

• ALLOW IT TO “UNWIND” TO THE RIGHT, HITS A “STILL POINT” AND THEN SPONTANEOUSLY ROTATES & SIDEBENDS LEFT AND EXTENDS

NOTE: VAN BUSKIRK DOES ACTIVELY & STOOD IN FRONT OF PATIENT

• RETEST . . . TO SEE IF CORRECTED !

FEW MEDICAL RESPONSES OCCUR THIS QUICKLY

Rib Cage Mechanicsan

Osteopathic Perspective

Rib Cage Mechanics Pump-Handle

Bucket-Handle

ClinicalApplication:

“pseudo-angina

WatervilleData

Impact( Medicare codes)

Exhaled Inhaled

MUSCLES: CLINICAL USE( EXPIRED DYSFUNCTIONS )

43

TREATMENTPRINCIPLES:

EXHALEDvs EXPIRED

ALTERNATIVEMETHOD

STABILIZESSCAPULA

X

X

X

MUSCLES: CLINICAL USE( INSPIRED DYSFUNCTIONS )

LOWER RIBS: BUCKET-HANDLEWANT TO USE SIDE-BENDINGTHEN STRETCH OUT FASCIA

UPPER RIBS: PUMP-HANDLEWANT TO USE FLEXION

POSTERIOR M.E.T. EFFORT AT END( GLIDES POSTERIOR END CEPHLAD )

44

Stiles’Pelvic model:an evolving model

PELVIC REGIONAN EVOLVING PERSPECTIVE

1960’s VIEW 1970 MITCHELL

80-90’s2013

TENSEGRITY & FRACTAL GEOMETRY:

• SI/J UNIQUE SIDE TO SIDE• FRACTAL / ROUGH & NON-LINEAR

PROVIDES A PROTECTIVE DESIGN !• WHY DENSE POST. S/I LIGAMENTS ?

( HOLDING TWO SURFACES APART ? )ENABLE COMPLEX SACRAL MOVEMENT ?

• ‘FLOATING COMPRESSION’ PLUS 6 FUNCTIONAL AXES . . . QUANTUM #

( INTERSECTING ITA AND OA’s )NOTE: STA IS ANTERIOR TO ITA . . . ROLE ?

• IF TENSEGRITY IS FUNCTIONINGDO WE NEED FORM / FORCE CLOSURE ?

IS THAT A BACKUP SYSTEM ?

HAS SIGNIFICANCE OF ROUGHNESS BEENMISINTERPRETED ?

( OCCURS DURING 2d & 3d DECADES )MITCHELL-

TENSEGRITY DESIGNENABLE COMPLEX

MOVEMENT PATTERNS AND PREVENT

‘WEAR & TEAR ? 47

“FLOATING COMPRESSION”DESCRIBES A

CLOSED STRUCTURAL SYSTEMCOMPOSED OF A SET OF

THREE OR MORE ELONGATED

COMPRESSION STRUTS WITHIN A

NETWORK OF TENSION TISSUES, THE COMBINED PARTS ARE MUTUALLY SUPPORTIVE

IN SUCH A WAY THAT THE STRUTS DO NOT TOUCH EACH OTHER,

BUT PRESS OUTWARD AGAINST NODAL POINTS IN THE TENSION NETWORK

TO FORM A FIRM, TRIANGULATED, PRESTRESSED

TENSION AND COMPRESSION UNIT

BEFORE AFTER

PALPATING THE SACRAL BASE ( 1970 TUTORIAL )

•Locate the P.S.I.S.•Glide thumbs medial & anterior to sacrum ( sulcus )

•Then glide thumbs superior to sacral base•I.L.A.: palpate sacral hiatus

Palpate inferior lateral to I.L.A. 49

Biomechanical Complexity: anatomical( Mitchell, Sr. always stressed this principle for every anatomical area )

Key: modify technique to patient uniqueness ! ! !( mastery rather than competency )

adduction-abduction

int. / ext. rotationKey to “fine-tuning”

L. SACRAL FLEXION: Rx MET PATIENT IS PRONE Greenman: technique description ( ABD 150 & I/R )

ABD /ADDUCT THE L.. LEG TO “LOOSE-PACK” THE LEFT S/I JOINT ( ALSO INT./EXT. ROTATE LEG )

LOCATE THE MTA OPERATOR DETERMINES THE MOST

EFFICIENT VECTOR DIRECTION WITH THEIR R. HAND ON LEFT ILA

USE RESPIRATORY ASSIST:INSPIRATION

RE-TEST MISTAKES: NOT REALIZING ABOVE

TASKS / ASSUME ALL SI/Js ARE THE SAME . . . SKILLS DEVELOP RAPIDLYWITH THIS APPROACH ! MONITOR

VECTOR

51

TEXT: GREENMAN 2d & 4th EDITIONS• ABD / ADDUCT TO APPROX. 150

• INT. ROTATE THIGH TO “OPEN S/IJ”• BUT . . . .

MTA ( LOCATE WITH A/P TRANSLATION )

LEFT SACRAL FLEXION

( functional )

“FLOAT”LEFT S/IJ( AS SIDEBEND TO RIGHT ) LOAD OR BEAR WEIGHT ON R. I/T

( BY SIDEBENDING TRUNK TO RIGHT ) THE I/T SACRUM ‘LOOKING AT’

FASCIAL LOAD ( SLOWLY ADD COMPRESSION

TOWARD

DYSFUNCTIONAL JOINT )

52

FOOD FOR THOUGHT:• “LOADED” RIGHT I/T, “LOOSE PACKED” LEFT S/IJ & FIND MTA• THIS LOCATES THE DBP FOR THE DYSFUNCTIONAL S/IJ• ADDED COMPRESSION TO “ACTIVATE” TENSEGRITY • IT WILL “UNWIND” AWAY FROM RESTRICTIVE BARRIER• AFTER THE STILL POINT, THE BODY AUTOMATICALLY

• GOES TOWARD THE PREVIOUS RESTRICTED BARRIER• FINDS THE “NEW DBP” & AXIS AUTOMATICALLY ! ! !

• ILLUSTRATE THE RAPID AND DYNAMIC “PLASTICITY” OF THE CNS ? BUOYANCY AND RESILIENCY POTENTIAL !

RL

P/N

I/P

A/D+

RIGHT ANTERIOR INNOMINATE: Rx MET PATIENT IS SUPINE

OPERATOR FLEXES R. HIP UNTIL THE ITA IS LOCATED

THE R. S/I JOINT IS THEN “LOOSE-PACKED” UTILIZING ABD/ ADDUCTION

AND I/R & E/R TO “FLOAT” AGAINST RESTRICTIVE BARRIER . . . Only prime movers activate

PATIENT ATTEMPTS TO EXTEND THE HIP vs YOUR COUNTER-FORCE

MISTAKES: NOT REALIZE ABOVE TASKS….. SYNERGISTS AND ANTAGONISTS ACTIVATED WITH MET EFFORT …. NOT CLEAN M.E.T. RESPONSE

ALTERNATIVES: LATERAL AND PRONE 53

LOCATEITA

RIGHT ANTERIOR INNOMINATE: Functional

“FLOAT”RIGHT S/IJ

( WHERE PALPATE )LOAD OR BEAR

WEIGHTON L. I/T

FASCIAL LOAD

54

RN

LEVEL

LEVEL

ESSENTIALS:• ANT. PELVIS IS ‘LOOKING’ LEFT

( SIDE LOAD )• RIGHT I/SJ IS DYSFUNCTIONAL

( SIDE FLOAT )

S +

L. SACRAL FLEXION

R. SACRAL EXTENSION

L/L SACRAL TORSION

L/R SACRAL TORSION

ANTERIORSACRAL BASE

LEFT LEFT RIGHT RIGHT

SULCUS LEFT DEEP RIGHT NORMAL

LEFT NORMAL RIGHT SHALLOW

RIGHT DEEP LEFT NORMAL

RIGHT NORMALLEFT SHALLOW

SITTING F.B.T. LEFT RIGHT RIGHT LEFT

L5 ROTATION RL RL RR RR

LORDOSIS SL. INCREASED

SL.DECREASED

SL. INCREASED

DECREASED FLAT

POST / INF. I.L.A.

LEFT LEFT LEFT LEFT

AXIS INVOLVED M.T.A. M.T.A. L.O.A. R.O.A.

SPHINX TEST NEGATIVE POSITIVE NEGATIVE POSITIVE

L. LEG LENGTH( MECHANICS )

L. LONG L. LONGR. SHORT

L. SHORTR. LONG

L. SHORT

SACRAL FINDINGS:

Clinical Application:Host + Disease = Illness ( clinical presentation )

• host + DISEASE = Illness • HOST + disease = Illness• HOST + DISEASE = Illness

Additional mechanisms:for explaining OMT outcomes

Cybernetics ( dynamic “feedback loops” )

Gen. Adaptive systems ( 1 system )

Complex systems ( multiple systems )

Fractal Geometry ( distribution issues )

Fractal / Chaos Physiology ( homeo-dynamics )

Autopoiesis ( dynamic S/F changes )

Multi-agent ModelingNetwork of NetworksEmergent Properties

7 Competencies:( P/P “ mirror” strategy )

• Osteopathic integration• Medical Knowledge

• Patient Care• Interpersonal Communications

• Professionalism• Practice-Based Care• System-Based Care

S/D can impact: 1, all, any comboof arms

THE “NEW” CONCEPTS AND LANGUAGE AVAILABLE TO OSTEOPATHY• CYBERNETICS: BILL JOHNSTON AND CHARLES BOWLES – FUNCTIONAL METHODS• AUTOPOESIS: COMPLEX & DYNAMIC STRUCTURE - FUNCTIONAL RELATIONSHIPS

( TERM NOW IN LITERATURE )

• 21 CENTURY MECHANISMS AVAILABLE TO EXPLAIN O.P.P. OUTCOMESBODY IS A COMPLEX FUNCTIONAL UNIT OF INTERCONNECTED SYSTEMS

Complexity & Family Practice:Systems & Complex Thinking

Annals of Family MedicineVol 12 no 1 Jan / Feb 2014

A.C.G.M.E. Educational Model

Experiential Educational Model( utilizing a patho-physiological “mirror” strategy )

• Action / Experience / cc. / symptom / sign

• Reflection / gather data / develop hypothesis

• Abstraction treat / test hypothesis / develop theory( establish a final diagnosis )

• Application / old, new or other

BOTTOM – LINEEducational Phenomenology

OsteopathicManagement

Whatis that

allabout ?

I have abetter

understandingnow !