Sacro-iliac Joint Dysfunction and Low Back Pain: Gentle
bruce@brucestark.com.au www.brucestark.com.au Sacro-iliac Joint Dysfunction and Low Back Pain: Gentle Techniques for Structural Alignment and Re-education AAMT National Conference 2015 Presentation Overview Review the structures involved in SIJ dysfunction Outline the principles of structural work from a positional release perspective Learn basic release positions for the psoas, pelvis, lumbars and sacrum Activate proprioceptive re-education of the pelvic girdle for SIJ balance Learn client home exercises for maintaining postural changes and structural alignment Symptoms and Consequences of SIJ Dysfunction Sciatic pain SIJ pain Pelvis rotation and leg length discrepancy Low back pain Hip socket pain or restricted movement Pubic bone pain Distorted sitting postures Gait imbalances Scoliosis/kyphosis 1|Page Copyright 2015 Bruce Stark Overview of the Bony Structures Partly synovial and partly syndesmosis (posterior sacrum to ilium – “ankle”-type) Sacral articular cartilage is hyaline cartilage and the iliac articular cartilage is fibrocartilage Sacral articular cartilage is 3 times thicker than iliac articular cartilage – 6 mm v 2 mm At birth surfaces are smooth and flat, developing uneven contour after puberty Early 20s the sacral articular surface becomes depressed and the iliac articular surface becomes elevated Two parts of the SIJ: cranial portion – points upward and slightly backward; caudal portion – points backward and slightly downward; angle of the articular surface – region between the cranial and caudal portions SIJ makes an angle of 20 degrees 2|Page Copyright 2015 Bruce Stark Ligaments Downward force on the sacrum is resisted by the ligaments supporting the SIJ which in turns stabilises the joints. Syndesmoses – interosseous or axial ligament which spans the gap between the sacrum and the ilium (deep to the posterior sacroiliac ligament) Direct support from the posterior and anterior sacroiliac ligaments; indirect support from the sacrospinous and sacrotuberous ligaments Also the iliolumbar ligaments from the TVPs of L4 and L5 to the iliac crest Pubic symphasis – fibrocartilage disc (4 mm thick) sandwiched between layers of hyaline cartilage; contributes to the “clamping effect” of the SIJs 3|Page Copyright 2015 Bruce Stark Axes of Rotation Malfunction on one side overloads the opposite side Malfunction at the lumbosacral junction overloads SIJ 4|Page Copyright 2015 Bruce Stark Sacral Torsion 5|Page Copyright 2015 Bruce Stark Shock absorption – in response to impact loads such as with the heel strike with walking or running Degeneration of SIJs will transfer the shock absorption to the lumbar vertebrae Nutation of the pelvis – forward rotation of the sacrum about the SIJs resulting in the posterior aspects of the ilia are drawn closer together and the ischial tuberosities move farther apart. Counternutation of the pelvis – backward rotation of the sacrum about the SIJs resulting in the posterior aspects of the ilia move farther apart and the ischial tuberosities are drawn closer together. 6|Page Copyright 2015 Bruce Stark Lumbar nerves enervate the joint capsules of the SIJs With unstable SIJs the normal interlocking of the articular surfaces can result in abnormal interlocking and result in sacroiliitis Anterior dysfunction of the SIJ – can happen when the torso is inclined forward and can be unilateral or bilateral. The normal shock absorption function in impaired. The lumbar segments are then overloaded and it creates low back pain. Women are particularly susceptible to anterior dysfunction just prior to and during menstration. Once anterior dysfunction has happened the likelihood that the sacrum on the ilium on the affected joint is greatly increased. Osteitis pubis – microtears in the disc and supporting ligaments in response to shearing forces 7|Page Copyright 2015 Bruce Stark Principles of Positional Release Structure governs function Exaggeration of the preferred posture/preferred direction commonly the distortion The body will release imbalances when it is in positions of comfort - no pain to release pain Follow what the body is doing rather than forcing it Use tender points to monitor the tissue for maximum relaxation or softening to identify the release position “Fine tune” the position by using gentle movements to stimulate the maximum state of relaxation around the joint Quality of Contact and Interaction Generally a gentle compression will stimulate and speed up the release within a joint or its surrounding tissues The most effective method is to do less to initiate the self-corrective reflex and to allow the person to do more for themselves - “Less is more” Non-investment in change - it is more important to notice what the outcome is rather than to try to create a specific outcome The body has many of the resources to balance itself - our role as Practitioner is to facilitate these naturally occurring processes Relaxed hand contact allows greater sensing capacity for the Practitioner Techniques Psoas Imbalance Indicators Femur Resistance to Internal Rotation Client is supine Practitioner places hand just proximal and posterior to the ankle Gently rotate the entire leg medially assessing for range of motion and ease of movement, especially at the level of the hip socket Resistance to internal rotation could be an indication of psoas restriction Assess only one leg/hip at a time Referred Pain Point Client is supine 8|Page Copyright 2015 Bruce Stark Assess for tenderness midway between the umbilicus and the ASIS Tenderness or restriction here may be in indicator of psoas restriction “C – Curve” Release Client is supine Practitioner assists the client in laterally flexing (“side bending”) their torso towards the affected side with client resting in that position Practitioner then gently abducts and slightly laterally rotates the leg on the affected side until the client’s leg reaches a position where it rests and relaxes naturally Practitioner applies compression up the client’s leg towards the hip by placing the client’s foot on the practitioner’s hip and then leaning slightly forward towards the client’s hip At this point, if it is comfortable for the practitioner, gently grasp the client’s hand to support the lateral movement After observing the rebound or release, gently return the client to a neutral position and recheck the imbalance indicators Note: Another way to release the psoas can be accomplished with the Lumbar 2 (L2) positional release. 9|Page Copyright 2015 Bruce Stark Lumbars Imbalance Indicators Imbalances in the lumbars can be indicated by referred pain points located bilaterally on the pelvis. L1 – Point medial to the ASIS L2 – Point midway between the ASIS and the pubic bone and either superior or inferior to the inguinal ligament L3 – Point on the lateral margin of the tensor fascia lata muscle as it crosses the gluteus medius muscle L4 –Point in the mid buttock at the centre of the gluteus maximus muscle L5 – Point medial to the PSIS Release Positions for L1 – 2 Client is supine Client bends knees and places feet on the table (if that causes discomfort the client can also bring up only one knee of that is more comfortable) Practitioner monitors the point of imbalance, grasps the client’s lower legs and supports the legs against the practitioner’s shoulder Practitioner steps forward towards the head of the table drawing the clients legs superiorly and resting supported over the client’s hips Practitioner allows the client’s legs to drop laterally until the point of imbalance is maximally softened After the release, the practitioner replaces the client’s legs onto the table and reassesses the point Note: It is possible to release all of the lumbar points using the release position for L1-2. 10 | P a g e Copyright 2015 Bruce Stark Release Positions for L3 – 4 Client is prone Practitioner grasps the client’s hip opposite to the affected side Practitioner then draws the client’s hip posteriorly and then folds towards the midline towards the indicator point until the point is maximally softened After the release, the practitioner replaces the client’s hip on the table and reassesses the point Release Positions for L5 Option One: Client is prone Client slides diagonally on the table allowing the leg of the affected side to hang off the side of the table Practitioner stands next to the table and supports the client’s leg by resting the client’s shin on the practitioner’s thigh Alternatively, the practitioner can use a chair and support the client’s leg on the practitioner’s thigh Use hip flexion, extension, abduction and adduction to find the position of the leg that maximally softens the point of imbalance After the release, assist the client by replacing their leg on the table and reassess the point 11 | P a g e Copyright 2015 Bruce Stark Option Two: Client is prone Client crosses the leg of the non-affected side across the back of the leg of the affected side Practitioner gently grasps the client’s crossed leg proximal and anterior to the knee and gently draws the leg across the midline until the point of imbalance has maximally softened After the release, the practitioner replaces the client’s leg on the table and reassesses the point Ilium Rotation Imbalance Indicators Leg Length Client supine Assess apparent leg length differences by bringing the client’s feet together and assessing discrepancies in leg length at the ankle Client prone Assess the Sacro-iliac joint imbalance point located 2.5 cm (1 inch) lateral and 2 cm (¾ inch) inferior to the PSIS The SI Joint indicator point will help in assessing which side is likely to be experiencing the imbalance Posterior rotation of the pelvis at the ilium creates an apparent Short Leg Anterior rotation of the pelvis at the ilium creates an apparent Long Leg 12 | P a g e Copyright 2015 Bruce Stark Posterior Rotation Release (Apparent Short Leg) Client is prone or side-lying Client abducts and flexes the hip of the affected side – “frogging” the leg Practitioner stands on the opposite side and exaggerates the posterior rotation by drawing the ASIS posteriorly with one hand whilst gently pressing the ischium of the same innomiate anteriorly creating a gentle twist of the ilium After the rebound or release, have the client straighten their leg and return to a neutral position as the practitioner reassess the imbalance indicator Anterior Rotation Release (Apparent Long Leg) Client is prone or side-lying Practitioner stands next to the affected side and flexes the client’s knee placing their hand proximal and anterior to the knee Practitioner gently draws the client’s leg posteriorly (hip extension) whilst pressing the client’s ilium anteriorly creating a twist of the ilium After the rebound or release, replace the client’s leg on the table and reassess the imbalance indicator 13 | P a g e Copyright 2015 Bruce Stark Isometric for Ilium Rotation Client is supine For anterior rotation (long leg): flex client's leg and move it medially. Have client press leg laterally. Follow through. For posterior rotation (short leg): flex client's leg and move it laterally. Have client press leg medially. Follow through. 14 | P a g e Copyright 2015 Bruce Stark Diagonal Ilium Rocking Client is prone. Place one hand on the client’s ilium just above the PSIS and the other hand on the opposite ischium. Initiate a “seesaw” movement following the body’s timing until the two sides balance. Sacrum Imbalance Indicators Tension or points of tenderness or restriction on the sacrum and especially along the sacral margins General Release Client is prone Practitioner assesses movement ease or preference in the following directions: superior/inferior; lateral (side-to-side); rotation clockwise/anticlockwise With each movement preference the practitioner gently holds and compresses the sacrum in each position until a rebound or release. It is also possible to “stack” all of the preferences into one release. 15 | P a g e Copyright 2015 Bruce Stark Tender Points on the Sacral Margin Client is prone Practitioner monitors the imbalance point and then draws the ilium and/or femur of the same side as the point towards the point until the point is maximally softened focusing on the pulls of the ligaments After the release, the practitioner replaces the hip on the table and reassesses the point Piriformis With client prone, check for tightness in the piriformis. Abduct their leg and rotate their leg medially. Have client rotate their leg externally with an isometric. Follow through. 16 | P a g e Copyright 2015 Bruce Stark Femur Rotation Imbalance Indicator Exaggerated medial or lateral rotation of the femur at the level of the acetabulum and may be related to lateral or medial foot orientation as well as restriction in rotational movement at the hip. Positional Release Client is supine Practitioner assesses movement preference by rotation of the femur medially and laterally asking for the client’s experience of what feels more comfortable or habitual Practitioner gently exaggerates the rotation preference and compresses the femur towards the hip After the release, the practitioner returns the leg to neutral and reassesses the preference 17 | P a g e Copyright 2015 Bruce Stark Note: It is best to include the seated isometric/isotonic to facilitate greater proprioceptive reeducation Seated Isometric/Isotonic Internal Femur Rotation Client seated Client crosses affected leg over the other leg—either across the thigh or the shin Practitioner draws the affected leg towards the midline whilst bringing the clients opposite shoulder also towards the midline Practitioner holds the client in this position whilst the client attempts to gently push their leg and shoulder away from each other (using on 10-20 per cent of their strength) After approximately 7 – 10 seconds the practitioner tells the client to relax and the practitioner follows through with the movement by moving the client’s leg and shoulder away from each other Repeat the isometric 2-3 times 18 | P a g e Copyright 2015 Bruce Stark External Femur Rotation Client Seated Client crosses affected leg over the other leg—either across the thigh or the shin Practitioner gently presses the clients leg laterally and holds the clients opposite shoulder as the client is seated upright Client then attempts to bring their leg and shoulder together whilst the practitioner holds the client in place (10 – 20 percent of the client’s strength) After approximately 7 – 10 seconds the practitioner tells the client to relax and the practitioner follows through with the movement by bringing the client’s leg and shoulder towards each other Repeat the isometric 2-3 times 19 | P a g e Copyright 2015 Bruce Stark Pelvic Flare Client is supine. Assess for pelvic flaring by placing your hands on both sides of the client’s pelvis at the level of the top of the ilia and press them directly towards each other. Then place your hands on both of the greater trochanters of the femurs and press again directly towards the mid line. Determine the preferred direction. Place one knee on the table against either the ilium or the trochanter and reaches across the client toward the opposite ilium or trochanter and compresses bilaterally toward the mid line. The practitioner can also isolate the movement by having the client align their body along the edge of the table whilst the practitioner uses his or her hip against the client’s hip and compresses the opposite hip toward the midline. 20 | P a g e Copyright 2015 Bruce Stark Proprioceptive Re-education Exercises Sitting on Sit Bones Client sits on a firm surface and slowly rotates the pelvis forwards and backwards finding the position in which the ischial tuberosities (sit bones) are pointing directly downward. The lumbar spine should be relaxed during this exercise with all of the movement coming from the pelvis. Moving the Hips and the Breath Client is supine. Client bends knees up and places feet shoulder width apart on the table. Client begins breathing deeply into their abdomen allowing the exhalation to be long, slow and relaxed. Client begins to visualise the breath moving out through the sacrum during the exhale. After several breaths, the client should begin to add weight to the bottom of their feet during the exhalation and then release the pressure on their feet during the inhalation. Client should feel a lengthening of the back muscles. References Alter, Michael (1996) Science of Flexibility, 2nd edition. Human Kinetics Publishing, Champaign IL Chaitow, Leon (2007) Positional Release Techniques, 3rd edition. Churchill Livingstone Elsevier, London Fogel, Alan (2009) Body Sense: The Science and Practice of Embodied Self-Awareness. WW Norton, New York, NY Fogel, Alan (2009) The Psychophysiology of Self-Awareness: Rediscovering the Lost Art of Body Sense. WW Norton, New York NY Hesch, Jerry (2011) “Sacral Torsion About an Oblique Axis”, in Erik Dalton, Dynamic Body: Exploring Form Expanding Function Jones, Lawrence (1981) Strain and Counterstrain. American Academy of Osteopathy, Indianapolis IN Kain, Kathy with Jim Berns (1997) Ortho-Bionomy: A Practical Manual. North Atlantic Books, Berkeley CA Overmyer, Luann (2009) Ortho-Bionomy: A Pathe to Self-Care. North Atlantic Books, Berkeley CA 21 | P a g e Copyright 2015 Bruce Stark Richard, Raymond (1986) Osteopathic Lesions of the Sacrum: Physio-pathology and Correction Techniques. Thorsons Publishers Ltd. Schwind, Peter (2003) Fascial and Membrane Technique: A manual for comprehensive treatment of the connective tissue system. Churchill Livingstone Elsevier. Still, A T. (1910) Osteopathy: Research and Practice. Reprinted 1992, Eastland Press, Seattle WA Sutherland, William (1990) Teachings in the Science of Osteopathy. Sutherland Cranial Teaching Foundation. Watkins, James (2010) Structure and Function of the Musculoskeletal System, 2nd edition. Human Kinetics Publishing, Champaign IL Resources For further training opportunities visit www.brucestark.com.au to get course offerings, class descriptions and further resources for learning Ortho-Bionomy and structural bodywork. www.facebook.com/BruceStarkOrthoBionomy @brucestark Detailed information on Practitioner Training Programmes can be found at: Ortho-Bionomy Australia Ltd www.ortho-bionomy.org.au Society of Ortho-Bionomy International www.ortho-bionomy.org Photographer: Chris Griffith Model: Hank Adam Thank you Chris and Hank for your help! 22 | P a g e Copyright 2015 Bruce Stark
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