Osteopathic Management Case Studies

The second and third procedures in a series of osteopathic management case studies.

By Kurt Heinking, DO

 

OMT
Facilitated Positional Release (FPR): Posterior Cervical Treatment Technique Implementation

Facilitate Positional Release (FPR)

Dysfunction
Example: C4 on C5 flexed (forward bent), rotated right, sidebent right (tissue
texture change, motion restriction, and tenderness on the right) - posterior C4 right.

Objective
Improve left rotation, sidebending and extension at C4-5.

 Discussion
The most common error in this technique is to lose localization as the head and neck are rotated. The cervical curve is taken out through flexion of the neck. Compression is added next. Then position the joint in the freedom of motion (sidebending and rotating left). A release occurs in as little as three-five seconds. The physician must control the head at all times.

 Physician Position
Standing at the head of the table.

 Patient Position
Lying supine.

 Procedure

  1. Palpate for tissue texture abnormality over the posterior component (C4 right). Place the fingertip of your left index finger over the posterior component. This is done by slipping your finger under the neck and “hooking” the right facet area of C4-5
  2. Your right hand (passive) cradles the head and flexes the c-spine down to and including C4. Maintain comfortable control of the head and neck throughout the procedure.
  3. With your right hand, introduce a mild compression force down to and including C4 on C5.
  4. Maintain this position over the proximal phalanx of your left hand.
  5. While maintaining this position, pull with your left index finger rotating and sidebending the head and neck to the right (down to and including C4).
  6. A release should occur in 3-5 seconds. Do not apply excessive force to the cervical spine. Be very gentle and specific.
  7. Return to a neutral position.
  8. Reassess. Has the motion improved?

 

OMT
Lumbar "Walk Around" Technique Implementation
HVLA/ME - Lumbar "Walk Around" Technique

Dysfunction
Example: L1 on L2, rotated right and sidebent right, extended

Use
Lower thoracic and all lumbar somatic dysfunctions.

Objective
Improve rotation and sidebending left and flexion of L1 on L2.

Discussion
This technique is especially useful for extended dysfunction’s in the
thoraco-lumbar junction (if it is modified to treat flexed dysfunctions, much of the rotational force is from above, and extension is maintained throughout the movement).

Localize the barrier through lateral translation. When performing this technique, it is important to keep the patient’s ischial tuberosities in contact with the table. Instructing the patient to turn their head to the side opposite to the dysfunction may enhance results by adding more rotation from above.

Physician Position
Standing behind the seated patient.

Patient Position
Patient sitting astride the end of the table with their back towards the physician. Keep their pelvis close to the edge. An electric table is useful for proper technique execution.

Procedure
  1. Instruct the patient to clasp their hands behind their neck.
  2. With your left arm, reach beneath the patient’s left axillae just below the shoulder, crossing the chest anteriorly. Place your left hand over the patient’s right arm, grasping the area of the right humeral head.
  3. Instruct the patient to slump forward until gaping (flexion) is palpated between the spinous processes of L1 and L2.
  4. Place the heel of your right hand over the right transverse process of L1. Translate the entire lumbar and low thoracic area across the midline to the right, by applying pressure with your body against the patient’s left axillae. This right translation engages the barrier and localizes the left sidebending force to L1 on L2.
  5. Keep the patient’s shoulders level and ischial tuberosities on the table.
  6. Now, rotate the patient to the left, this is accomplished by walking around the end of the table to the right while combining a pull with your left arm. Maintain localization by pressure through your right hand until the barrier is engaged. Firmly fix your right elbow against your right side. After the barrier is engaged by lateral translation, rotate L1 left by pushing with your right hand, maintaining the lateral translation right. Your right arm should be functionally fixed to your torso, or you may fix your right elbow to your right side.
  7. Your left arm keeps the patient’s torso flexed. Do not allow the L1 somatic dysfunction to extend (lose the flexed position) during the corrective force, as this will probably render the technique ineffective. The dominant corrective force in this technique is with the right hand on the posterior transverse process, with a secondary force from above.
  8. HVLA treatment- a quick increase in left rotation of L1 with an anterolaterally-directed force through the heel of your right hand by shifting your body around to the restrictive barrier. At this point your feet do not move.
  9. Use your entire body as a unit and maintain good body mechanics. Be sure to engage the barrier before your thrust. Do not “wind up and thrust”.)
  10. For Muscle Energy Modification – the sidebending component can be addressed with a muscle energy approach by depressing the patient’s left shoulder and asking them to raise their left shoulder against your holding force. Hold for 3-5 seconds and then relax. Pause.
  11. Engage the new barrier and repeat the procedure a total of three times.
  12. Reassess motion.

Dr. Heinking is a 1994 graduate of the Chicago College of Osteopathic Medicine / Midwestern University and is currently the Assistant Chair in the Department of Osteopathic Manipulative Medicine at the Chicago College of Osteopathic Medicine / Midwestern University.