AOCPMR Mid Year Meeting and Scientific Seminar

April 5, 2014
Low Back Pain OMM Workshop

PARASPINAL INHIBITION
Indications: Thoracic or lumbar paraspinal muscle
tension associated with back pain, chest wall
pain, and other problems.

Contraindications: acute vertebral, rib fracture,

unstable cardiac arrhythmia, or bowel
obstruction

Patient position: supine or with posterior

transverse process up

Physician Position: Sitting or standing facing the

patient

Discussion: A commonly used technique that

applies counter traction along the paraspinal
muscles. It can be used in treating cervical,
thoracic, and lumbar somatic dysfunctions with small variations of the patients body position. As the
paraspinals are adjacent to the sympathetic chain ganglion, there may be some facilitation in
sympathetic tone normalization. Therefore this technique is often used in treating lymphatic and
pulmonic disease processes in addition to back pain. As the technique is passive and can be adopted to
almost any patient position, it is a favorite by many physicians to be used in the hospital setting.

Technique Notes:

TEXAS TWIST (Thoracic thrust-

supine/Cross hand pisiform
thrust)
Indications: restricted thoracic rotation related to back pain, chest wall pain, shoulder pain, or other
problems.

Contraindications: joint inflammation, joint hypermobility, acute sprain, acute fracture, vertebral
cancer, and vertebral fusion

Patient position: Prone

Physician Position: Standing at the side of the table, opposite side of posterior component (rotation
somatic dysfunction).

Discussion: This technique is most useful for flexed thoracic somatic dysfunctions and there are many
variations of the technique. Most variations are based on the placement of the hands for the thrust or
orientation of the physician to the patient. This technique can be modified to treat rib somatic
dysfunction as well. Physicians must be careful not to overuse this technique in a patient so that an
extension body position is not accidently induced over time.

Technique Notes:

KIRKSVILLE CRUNCH (Thoracic/Rib Thrust-supine)

Indications: restricted thoracic
rotation or rib motion related to
back pain, chest wall pain,
shoulder pain, or other problems

Contraindications: joint
inflammation, joint hypermobility,
acute sprain, acute fracture,
costochondral subluxation,
vertebral cancer, vertebral fusion,
and severe osteoporosis

Patient position: Supine

Physician position: Standing on

side of the posterior component
with his hands placed on the
segment below.

Discussion: This is a very common treatment with many variations to treat both thoracic (flexed and
extended somatic dysfunction) and rib somatic dysfunctions. Variations are often dependent on
physician hand placement (over transverse process, segmental below, opposite transverse process, over
rib angles), patient arm placement (hands behind neck or folded across chest), if the physician controls
head position, or thrust direction. The Kirksville crunch can be very effective in treating flexed
dysfunctions as the physicians hands act as a fulcrum providing extension during thrust applications.
Often in real word scenarios the multiple variations are combined into one generalized technique that is
modified to provide the best localization of the somatic dysfunction and application of force to the
restrictive barrier.

Technique Notes:

LUMBAR ROLL (lateral recumbent with thrust)

Indications: restricted lumbar rotation
associated with back pain, scoliosis, and
other problems

Contraindications: Acute lumbar sprain,

lumbar joint hypermobility,
undiagnosed radiculopathy, acute
vertebral fracture, acute herniated or
ruptured disc, and vertebral cancer or
infection

Patient Position: recumbent position

with rotational somatic dysfunction
facing down.

Physician Position: Standing on the side

of posterior (rotational) component with the physicians cephalad arm stabilizing the shoulder.

Discussion: One of the few recognized HVLA techniques that can be used to treat lumbar somatic
dysfunctions. Positioning of the patient is similar to lateral recumbent muscle energy technique, which
is often used prior to the application of a thrust. Localization with this technique requires careful cross
rotational forces directed towards the somatic dysfunction. This localization is obtained by positioning
the patients upward shoulder towards the table with the physicians cephalad arm while the physicians
caudal forearm provides a counter rotation at the patients hip/buttocks. If localization cannot be
obtained, it is often because the patients shoulders are no longer squared to each other. If there is
continued difficulty with localization or difficulty in patient positioning, the lumbosacral
articulatory/trust (OB Roll) is often employed.

Technique Notes:
 SACRAL BLT
Indications: restricted lumbosacral
motion associated with back pain, pelvic
pain, headache, and other problems

Contraindications: acute sacrum fracture

Patient position: supine

Physician position: seated with one or

two hands on the sacrum with fingertips
at the base and palm extending towards
the coccyx.

Discussion: Balanced ligamentous

tension (BLT) is generally thought of a
technique that alleviates unbalanced ligament tension created due to altered mechanical forces. Often
BLT is confused with myofascial release but in BLT the releasing forces are inherent to the patent with
the physician only assisting in the achievement of balance, not causing it. (Commonly used inherent
motion models: Fluid models and respiration models.) The techniques are often thought of in 3 parts.
The first aspect is to disengage and exaggerate the diagnosed somatic dysfunction during its indirect
phase until the still point is reach. Afterwards the physician follows a direct approach to bring the
surrounding structures back into the diagnosed dysfunction. Within the sacral BLT, appreciation of the
still point can be difficult with the various overlying sacral motions. Often focusing on the craniosacral
flexion (base posterior) and extension (base anterior) allows a physician to gain a better appreciation of
the layers of movement within the area and thereby a better palpatitory understanding of the
approaching still point. A common modification that is used to allow for increased sensory feedback at
the hands is to lean back on the elbows which relaxes your hands under the patient. If a still point is still
difficult to appreciate or the patient is not tolerating the treatment position, consider lumbosacral
compression and decompression.

Technique Notes: