World Congress on Low Back & Pelvic Pain Conference Abstracts

Introduction: Sacro occipital technique (SOT) has long discussed that the anterior and posterior aspects of the sacroiliac joint (SIJ) are completely different in both their anatomy and function. The posterior weightbearing aspect of the SIJ when mobile would be dysfunctional (SOT’s category two) whereas the anterior nutative aspect of the SIJ when too “stable” would be dysfunctional (SOT’s category one).

Purpose/Aim The purpose of this survey was to see if an internet survey might be feasible and if preconception of a possible syndrome might influence a doctor’s method of diagnosis and treatment.

Materials and Methods As a pilot study questions regarding SIJ hypermobility or fixation were asked of internet chiropractic groups related to just SOT and others not technique based. Those who stated they used SOT as a technique in their office were separated from those who did not use SOT’s method of chiropractic.

Results A small sampling survey was taken of SOT practitioners (N=53) and some practitioners not familiar with SOT (N=11). Those who practice SOT found that relating to patient lumbopelvic presentations that 13.1% had SIJ fixation, 74.5% had SIJ hypermobility syndrome, and 16.4% had lumbosacral involvement. Those who did not practice SOT found that relating to patient lumbopelvic presentations that 43.1% had SIJ fixation, 16.6% had SIJ hypermobility syndrome, and 40.3% had lumbosacral involvement.

Relevance As with with most systems of healthcare the doctor’s bias and perspective can affect their diagnostic finding and treatment options.

Conclusions If there were an entity such as a hypermobile SI joint[1] it would behoove chiropractic to be cognizant of this syndrome[2] and see if appropriate tools can be developed to help differentiate it from a fixated SI joint. More investigation into this phenomena could offer greater understanding into whether: (1) a greater number of patients who see SOT chiropractors have hypermobile SI joints, (2) SOT chiropractors are looking at patients with an assumption that the patient will likely have a hypermobile SI joint, and (3) it is possible that SI joint hypermobile is an overlooked syndrome in chiropractic.

Discussion Is a dysfunction associated with the posterior weight bearing aspect or the anterior portion associated with normal nutation? It is important to differentiate between a fixated SI joint secondary to a anterior joint dysrelationship, such as a pelvic torsion, or a fixated SI joint secondary to a posterior hypermobile joint causing neuromuscularly a “splinting” due to increased nociception and local muscle hyperfaciliation leading to increased myofascial tension3. Most SOT category indictors are related to increased muscle tension or pain and related altered body function. One way of evaluating whether appropriate treatment is being rendered is the lessening of pain or tension at those specific indicator points as well as improved musculoskeletal function.

Implications It is possible that being cognizant of SIJ hypermobilty/fixation may improve patient outcomes and future research should investigate what subset of patients are presenting with this condition.

References

1. Eichenseer PH, Sybert DR, Cotton JR. A finite element analysis of sacroiliac joint ligaments in response to different loading conditions. Spine (Phila Pa 1976). 2011 Oct 15;36(22):E1446-52.
2. Binkley J, Finch E, Hall J, Black T, Gowland C. Diagnostic classification of patients with low back pain: report on a survey of physical therapy experts. Phys Ther. 1993 Mar;73(3):138-50; discussion 150-5.
3. Knutson G, The Sacroiliac Sprain; Neuromuscular Reactions, Diagnosis and Treatment with Pelvic Blocking, Journal of the American Chiropractic Association, Aug. 2004, 41(8): 32-9.

Introduction: A 57 year-old right-handed white male, presented in our offices with a chief complaint of acute sudden onset left jaw pain. The patient gave a history of a three-day episode of jaw, neck and ear pain, with no known cause. There was concern, due to the nature and degree of irritation, that he might possibly have an infective process (e.g., swelling pain, discoloration and pain to palpation). Therefore, prior to beginning treatment, dental x-rays were obtained, which were found to be negative.

Purpose/Aim Was the patient’s exquisite styloid process pain related to a relationship between styloid process sensitivity and ipsilateral L5/S1 disc compression as proposed by DeJarnette[1]?

Materials and Methods Evaluation noted that with palpation marked sensitivity of the left styloid as well as exquisite sensitivity along the right sciatic track with a positive straight leg raise at 45 degrees. The patient was treated with sacro occipital technique (SOT) category three orthopedic blocking[1], which utilizes the left styloid process as a guide to possible related ipsilateral L5/S1 discopathy affecting sciatic nerve irritation. As decompression to the ipsilateral L5/S1 is produced the styloid process is palpated for sensitivity.

Results As treatment was provided, the sensitivity to the styloid process was rapidly eliminated. Concurrently the right sciatic pain and related muscle tension in the right thigh significantly diminished. Diminished tension was found in the plantar fascia of the right foot with a visualized reduction in clubbing of that same foot.

Conclusions In this single subject case report of a patient presenting with acute styloid process sensitivity, differentiating the patient’s presentation was essential. Once a dental contribution was ruled out, other factors were investigated. A relationship between the styloid process sensitivity, the lower back pain and antalgia was assessed and treated. As the lumbar spine was treated, the styloid process sensitivity was eliminated and the patient had significant improvement of function with a reduction of pain. Further studies are needed to determine what subset of the population has this relationship and to facilitate greater communication between professions treating this entity.

Discussion Part of any differential diagnosis with a patient that presents with significant styloid process pain could include determining if there is concurrent low back pain related to L5 involvement.

Implications Ruling out ascending myofascial imbalance from the lower back causing styloid process sensitivity could facilitate improved differential diagnostic protocols thus improving patient care and outcomes.

Reference

1. DeJarnette, MB. Sacro Occipital Technic. Privately Published: Nebraska City, Nebraska, 1984:210-33.

Introduction: A 47-year-old female patient presented with chief complaints of pain when chewing, jaw pain, limited mouth opening range of motion, and TMJ crepitus. She was found to also present with generalized joint hypermobility (GJH), a hereditary connective tissue disorder characterized by lax joints and the presence of musculoskeletal symptoms[1]. Following dental evaluation and delivery of dental orthotics the patient was referred for concurrent chiropractic, which found indicators of sacroiliac joint hypermobility (sacro occipital technique’s – SOT – category two).

Purpose/Aim: The purpose of this case report is to share a novel protocol for the treatment of chiropractic and dental treatment of a patient with a temporomandibular joint disorder (TMD) that presented with GJH[2] affecting the SIJ and TMD.

Materials and Methods: Following orthotic and chiropractic care at 8-weeks, the capsulitis of TMJ was no longer present and procaine injections into the posterior TMJ capsule were initiated at one month intervals, followed by prolotherapy. Dentally the patient received prolotherapy injections every 2-3 weeks on the side of TMJ adhesions and joint restriction, secondary to the hypermobile retrodiscal tissue. The injections (2% procaine, initially 10% and then 25% dextrose and bacteriostatic water) were localized in the retrodiscal tissue and sometimes in the ligaments or adhesive tissues to break down scarring. The prolotherapy was also used to create increased retrodiscal tissue tension to facilitate a posterior ‘pull’ on the disc, owning to the anteriorly displaced disc. SOT chiropractic care facilitated SIJ stabilization and TMJ cranial function and dental care helped stabilize occlusion and condylar position, which were continued over a 10-month period.

Results: Following concluding treatment the patient was free of most pain, had full range of motion in the cervical and lumbar spine, negative sacroiliac hypermobility findings with improved function, and could open her mouth greater than 42mm (initially presented with 28mm opening) with normal joint tracking and translation.

Relevance: Patients with GJH with concurrent TMJ and SIJ hypermobility may represent a subset of patients needing concurrent chiropractic and dental interdisciplinary care.

Conclusions: Concurrently her sacroiliac joint hypermobility syndrome and related soft tissue tension patterns in the lower extremity, cervical spine, and jaw region have also significantly improved.

Discussion: In general, with chronic disc displacement without reduction, there are strained, stretched ligaments in the posterior joint space. When cranial/chiropractic manipulation reduces the disc but it doesn’t stay reduced, prolotherapy3 is indicated to strengthen and tighten the posterior band of ligaments. The chiropractic care worked closely with the dental application of prolotherapy by informing the dentist when the disc and condyle were in an optimal position. Once in an optimal position the goal was to inject the retrodiscal tissue to help support the disc position on joint translation and preventing close-locked positioning.

Implications: With chronic unresolving TMJ or SIJ hypermobility a patient should be evaluated for GJH and concurrent chiropractic and dental care, incorporating prolotherapy for the posterior TMJ capsule, may be indicated.

References:

1. Hakim AJ, Grahame R. A simple questionnaire to detect hypermobility: an adjunct to the assessment of patients with diffuse musculoskeletal pain. Int J Clin Pract. 2003 Apr;57(3):163-6.
2. Hirsch C, John MT, Stang A. Association between generalized joint hypermobility and signs and diagnoses of temporomandibular di­sorders. Eur J Oral Sci. 2008;116:525-30.
3. Hakala RV. Prolotherapy (proliferation therapy) in the treatment of TMD. Cranio. 2005 Oct;23(4):283-8.

Introduction: A 47-year-old female, entered my office stating that 3 days ago she began to feel pain in her low back and left leg and has progressively gotten worse. She described the pain as a 9-10 on a pain 1-10 pain scale with 10 being most painful pain imaginable and her functional capacity was graded at 20%.

Purpose/Aim: The purpose of this paper is to share how conservative sacro occipital technique SOT chiropractic care helped a patient with severe sciatica return to normal functional capabilities in a relatively short period of time.

Materials and Methods: SOT specific protocols were used to determine the appropriate treatment protocols and the patient was treated with category three protocols for disc compression and sciatica[1]. This included category three pelvic block protocols for severe lumbosacral discopathy as well as specific body reflex points to guide, side of contact, direction of vector, and location of vertebra to treat. SOT soft tissue therapies to the psoas and piriformis were included to facilitate pain reduction and improve function.

Results: After the initial two weeks of care (March 10, 2010) the patient showed 90% reduction of pain with 90% improvement of her functional capacity[2]. The patient continued to make excellent progress and continued to resume normal activities of daily living without pain or discomfort, and by June of 2010 was asymptomatic. To determine patient’s long-term functional status an MRI was taken on March 9, 2010 which revealed a “L3-L4 central disc protrusion and annular tear, a listhesis at L4-L5, and a 16mm L5-S1 left paracentral epidural mass effacing the descending left S1 nerve within the lateral recess.”

Relevance SOT chiropractic care may be a worthwhile first step low-risk intervention before attempting more aggressive pharmaceutical or surgical therapies known to have greater risk.

Conclusions It is significant that the patient had reduction of pain and improved function, even though the MRI still revealed a L5-S1 16mm left paracentral epidural mass.

Discussion This case is particularly interesting because of the patient’s positive clinical response to a low-force intervention (SOT care) when presenting with exquisite levels of pain, antalgic positioning, and marked limitations of function.

Implications Of significance is the patient’s reduction of pain and increase in function in the presence of MRI findings, creating a clinical conundrum when therapies are based upon MRI findings alone[3].

References:

1. Piera GJ, Dwyer PJ, Blum CL. The Effect of Coughing to Release the Dura in Category Three Patients Experiencing Sciatica: Three Case Reports. Chiropractic Journal of Australia. Sep 2004; 34(3).
2. Hahne AJ, Keating JL, Wilson SC.  Do within-session changes in pain intensity and range of motion predict between-session changes in patients with low back pain? Aust J Physiother. 2004;50(1):17-23.
3. Carragee E, Alamin T, Cheng I, Franklin T, van den Haak E, Hurwitz E. Are first-time episodes of serious LBP associated with new MRI findings? Spine J. 2006 Nov-Dec;6(6):624-35.

Introduction: Sacroiliac joint (SIJ) disorders during pregnancy are considered relatively common as the hormone relaxin increases SIJ laxity, which is assumed to induce pelvic girdle pain and/or low back pain (PPLP). Sacro Occipital Technique (SOT), a method of chiropractic, has one aspect of its analysis and care, which focuses on patients with SIJ laxity or instability, called category two.

Purpose/Aim: The purpose of this paper is to discuss the inclusion of the active straight left raise (ASLR) test as a potential part of SOT diagnostic regimen for the treatment of pregnancy-related SIJ disorders. In addition, this paper will also review the literature concerning the use of the sacroiliac support belt as both a diagnostic and treatment modality for this common presentation.

Methods: A review of the chiropractic literature was performed to evaluate the reliability or validity of SOT’s arm fossa test (AFT) which is commonly used to diagnose and evaluate treatment for SIJ disorders, such as PPLP. A broad-based review of the literature was also performed to evaluate any other tests that could be integrated into the SOT paradigm of evaluation and treatment as well as the value of any pelvic support belts for SIJ instability.

Results: The literature for SOT’s AFT indicated some intraexaminer reliability and validity[1]. The broad-based review found that the ASLR test has good reliability and validity for the evaluation of SIJ disorders, particularly in pregnancy[2]. In the later stages of pregnancy an unstable SIJ might be supported with a SIJ support belt[3] and its need and successful use could be monitored by a combination of the AFT and ASLR tests.

Relevance: SIJ compression caused by the doctor’s hands, a SIJ support belt, or the pelvic blocks may offer a good opportunity to use the ASLR and AFT as a means to study the need for treatment of SIJ instability and the efficacy of the treatment rendered.

Conclusion: Simple tests such as the AFT and particularly the ASLR may offer good options to monitor pre- and post-treatment of PPLP and SIJ in this specific subset of patients.

Discussion: The supine SOT pelvic block placement used to reduce SIJ or pelvic stability in pregnancy might incorporate both the AFT and ASLR as diagnostic and assessment tools.

Implications: Developing diagnostic and treatment strategies for pregnant patients with PPLP and SIJ instability is important due to the need for low risk modalities for the mother and fetus.

References:

1. Hestœk L, Leboeuf-Yde C, Are chiropractic tests for the lumbo-pelvic spine reliable and valid? A systematic critical literature review. J Manip Physiolog Therap. May 2000;23:258–75.
2. Mens JM, Vleeming A, Snijders CJ, Koes BW, Stam HJ. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine (Phila 1976). 2001 May 15;26(10):1167-71.
3. Mens JM, Damen L, Snijders CJ, Stam HJ. The mechanical effect of a pelvic belt in patients with pregnancy-related pelvic pain. Clinical Biomechanics (Bristol, Avon). 2006, 21:122-127.

Introduction: Sacro occipital technique’s (SOT) method of treating lumbosacral disc, sciatica, and related myofascial dysfunction is called category three.  SOT allows for conservative management of lumbar herniated discs and their possible affects on the thecal sac and CSF circulation. The hallmark of the category three technique is the use of prone pelvic blocks utilized to reduce pelvic torsion and through a triangulation process attempt to reduce or central radicular pain and improve function.

In a case study a 53-year-old male with significant low back and radicular pain presented for chiropractic evaluation following mild injury. MRI findings included large uncontained central disc herniation at the L4-L5 level. Chiropractic intervention consisted of sacro-occipital category three procedures. The patient responded well to a 6-week intervention and follow-up MRI at 5 months demonstrated significant reduction in the size of the herniation.  They concluded that characteristic of category three technique forced used “are low force and do not involve placing torsional stress on the low back, and potentially may be well tolerated and safe for patients in high-level acute pain that is often associated with symptomatic lumbar disc herniation [1].”

Disc Technique [2] along with the “Step Out Toe Out” maneuver (SOTO) [3,4] are central to the SOT category three protocol.  The SOTO diagnostic and treatment procedure is a core part of SOT’s category three (lumbopelvic problems) protocol.  It serves to not only identify and treat subluxations of the pelvis and lumbar spine, but also determines the degree of involvement of the surrounding soft tissues [3,4].   The purpose of the paper is to describe 2 case reports of symptomatic sciatica and lumbar disc herniation, successfully treated using sacro-occipital chiropractic technique procedures.

Case Reports: Patient #1 is a male patient seen September 2005 presenting with right lateral posterior thigh pain into the right leg consistent with sciatica which had persisted for two days.   He had no prior pertinent history.  Patient #2 is a male patient seen August 2005 presenting with lower back pain localizing to the lumbosacral region and right sacroiliac and hip joints with radiculitis below knee.  He presented with his body leaning to the left as an antalgic accommodation.  He had a chronic history of low back pain.

Treatment/Intervention: Patient #1 received category three-block treatment and was treated for a right piriformis muscle syndrome incorporating the right iliofemoral and SOTO procedures.  Cervical spine was accessed and treated for reduced cervical range of motion.  Patient #2 received category three-block treatment and was treated for a left piriformis muscle syndrome incorporating the left iliofemoral and SOTO procedures.  Cervical spine was treated utilizing the SOT cervical stairstep figure eight technique.

Results: Patient #1 was treated for 6 office visits through mid October of 2005 patient had significant improvement with decreased pain and improved function.  The SOTO test was negative and cervical range of motion was both normal and symmetrical.  Patient #2 was treated for 8 office visits through mid September 2005 with reduced pain as well as reduced peripheralization with pain not below the knee.  Psoas muscle tension had been reduced and cervical range of motion was normalized in range of motion.

Discussion: Developing an effective method of treating traumatized lumbosacral joints, discs, and related myofascia that is low force and would reasonably offer low risk is of value in the treatment of these complex disorders.  SOT category three-block placement offers a method of treating lumbosacral discopathy without imparting forceful torsion, rotation, or pressures to sensitive swollen tissues [1].  Incorporating myofascial diagnosis and treatment methods of the SOTO [3] and sitting disc technique [2] help expand the ability to treat piriformis muscle syndrome, sciatica, and disc bulging or herniation. The SOTO (Step Out Turn Out) maneuver is purported to help differentiates between lumbar disc lesions from a piriformis muscle syndrome. Additionally the SOTO maneuver is also used to assist diagnosis into the type and severity of the disc lesion [3,4].

Based on Blum et al study [5] there are various theories as to why there would be this increased CSF circulation in the lumbosacral region following the application of the sitting disc technique.   These might be associated with an actually mechanical increase in disc height through a form of distraction on the disc and local L4/L5 decompression, balancing tensions on the related meningeal or thecal structures, and affects of increased CSF fluctuations and circulation secondary to diaphragmatic or vascular influences.

The category three treatment protocols involve the use of pelvic blocks, the SOTO maneuver, and sitting disc technique [2].  With the two cases discussed each patient noted significant improvement with this treatment methodology.  With a subset of patients with severe pain there can be a high fear avoidance behavior and the slow gentle pressure may be a viable option for treatment.  Ideally conservative low risk methods of care for low back discopathies, versus the risks associated with medications, epidurals, and surgeries, would be preferred. Conclusion: This report suggests that chiropractic treatment of symptomatic lumbar disc disorders may, in certain cases, be effectively treated via use of SOT procedures: pelvic blocks, SOTO, and sitting disc technique. The procedures utilized in this technique are low force and do not involve placing torsional stress on the low back, and potentially may be well tolerated and safe for patients in high-level acute pain that is often associated with symptomatic lumbar disc herniation. Further study is needed to determine the most effective and best tolerated strategies to be used in the chiropractic setting for the treatment of symptomatic lumbar disc herniation.

References:

1.             Pfefer, MT, Rasmussen S, Uhl NS, Cooper S, Treatment of a lumbar disc herniation utilizing sacro occipital chiropractic technique Proceedings of the ACC Conference X, Journal of Chiropractic Education Spr 2003; 17(1): 72.
2.      Getzoff H, Disc Technique:   An Adjusting Procedure for any Lumbar Discogenic Syndrome   The Journal of Chiropractic Medicine Fall 2003; 2(4): 142-4.
3.      Getzoff H. The Step Out-Toe Out Procedure: A Therapeutic and Diagnostic Procedure. Chiropractic Technique. Aug 1998; 10(3): 16-8.
4.      Remeta EM, Indicators for Disc Herniation Supported by Magnetic Resonance Imaging (MRI): Poster Presentation 9th Annual Clinical Meeting of the American Academy of Pain Management, Las Vegas, NV, Sep 1998.
5.      Blum CL, Pick MG, Lovett L, Sitting disc technique: video myelogram fluoroscopy study Proceedings of the 2005 International Conference on Chiropractic Research: Sydney Australia Jun 16-18, 2005: 272.

Introduction: The ability for an athlete to perform consistently and at their peak is of utmost importance in high performance athletic activities. In spite of demanding training schedules to accomplish this task, it is not uncommon for an athlete to have an “off day.”  Explored in this case study is whether chiropractic care could be valuable for elite athletes who have their ability to train, recover, and excel in their specific activity [1].

Chiropractic care of athletes has been growing over the past few decades [2]. and in a survey was performed of 35 health professionals, including physicians, physiotherapists, athletic therapists and chiropractors.  The survey determined that sport medicine has an emphasis on performance, which is the basis for a client-centered model of practice. These two elements have provided the main grounds for the inclusion of chiropractic into sport medicine. While the common understanding is that ‘athletes wanted them’ has helped to secure a position for chiropractic within the system of sport medicine professions, this position is marked by ongoing tensions with other professions over the scope and content of practice, and the nature of the patient-practitioner relationship [3].There are various types of chiropractic care one method entitled sacro occipital technique (SOT) developed by DeJarnette evaluates the role of biomechanical faults. DeJarnette attempted to create a generalization of patients presenting for chiropractic care so that predictability could be attained for specific testing indicators that could be used for diagnosis and evaluate a patient’s response to treatment.  The category system could be briefly described as follows: category one relates to anterior sacroiliac (SI) joint fixation with subsequent reduced nutation; category two relates to SI joint hypermobility, and category three relates to lumbosacral discopathy often with accompanying sciatica [4,5].Case Report Subjects: The following three subjects in this study are patients, receiving normal evaluations and treatment and that this was a retrospective use of data from their charts.  Three subjects were used in this study: (1) Male professional mountain biker age 33 years old participating in multiple iron man triathlons, (2) Female Olympic mountain biker, age 37 years old, and (3) Male tri-athelete age 55 years old. Due to the nature of their endeavors multiple pains, discomforts, muscle “pulls,” and aches occur.  These would vary from neck pain, gluteal tightness, pain in the Achilles tendon, knee pain, TMJ tension, wrist pain, and delayed recovery from physical exertion.  All participants in this study at one time had all of the above symptoms as well as others.Method: The three subjects were examined and evaluated using sacro occipital technique (SOT) procedures, including SOT categorization, testing for symmetry of muscle flexibility, strength and function, sensitivity to palpation of specific muscle’s bellies and tendons. Specifically subjects were evaluated by manual muscle testing of the lower extremity musculature (i.e. quadriceps, hamstrings, gluteal group, gastrocnemius, etc.), symmetry of flexibility of muscle groups (piriformis/gluteus medius, iliopsoas, etc.) positional stability tests (e.g., single leg stances, balancing on rollers, etc.) and palpation of lower extremities (including Achilles tendon) musculature and joints for increased sensitivity.The manual muscle tests were considered positive if they demonstrated any of the following: 1) weakness 2) cramping on exertion 3) pain on exertion 4) asymmetry in strength from one side to another. Stability tests were considered positive if a differential in capacity from one side to another was demonstrated and/or an inability to perform the test on either side.Results: Following the SOT blocking procedures [4,5], which would vary between category one or two interventions, the three patients demonstrated greater strength in the weakened muscles, more stability where stability was diminished, reduced pain when pain was present on muscle testing or palpation and absence of cramping on muscle testing. SOT findings included reduced tenderness to palpation, improved postural stability testing, and, all improved during each office visit and would correspond to improved function, reduced pain, and accelerative recovery from injury.The following are the most common findings with each patient however there were times that a patient might present with completely different set of symptoms or dianoses due to accidents and crashes during athletic competition.1)  Patient #1 presented with cramping on exercise, fatigued and low energy, neck and  shoulder stiffness, difficult getting heart rate “up,”    He would get treated for a week or two and then travel for 6 weeks, generally receiving care 8-12 times per year. Response to the care noted significant improved perceived effort, greater capability of exertion, and body discomfort.2)  Patient #2 presented with stiffness in her neck and upper back, pain in wrists, low back strain, gluteal and hip discomfort. Response to care included elimination of wrist pain, greater flexibility of neck and upper back and reduced exertion on lower back and hips.3) Patient #3 presented with stiffness in the neck, pain and limited range of motion in his left shoulder, tightness and tenderness on the right hip with radiation towards the knee, as well as fatigue to legs on exertion.  Response to care included increased range of motion in neck and shoulder with improved strength, reduced pain in right hip, gluteal muscles, the lateral aspect of the lower extremities, and reduced effort on exertion.Discussion: It is a matter of speculation as to why following SOT category treatment there was increased function and improved outcomes relating to the patient’s muscle(s) pain, asymmetry, and altered strength. Based on the response to care from these three patients perhaps what is considered to be therapeutic care with physical therapy interventions may be missing a key component, which is the SOT categorization and treatment.Conclusion: What is suggested in this study is that the application of these chiropractic procedures, when indicated, could enable the performance conscious athlete to enhance their capabilities and produce more consistent outcomes when regularly applied.  Further research is indicated to determine which athletes would best respond to this care and at that time have a control group so a comparative study could be performed.References:

1.      Lopes MA. Chiropractic spine care for the athlete.  Top Clin Chiropr. 1997 Jun;4(2):9-26.
2.       Stump JL, Redwood D. The use and role of sport chiropractors in the national football league: a short report. J Manipulative Physiol Ther. 2002 Mar-Apr;25(3):E2.
3.      Theberge N. The integration of chiropractors into healthcare teams: a case study from sport medicine. Sociol Health Illn. 2008 Jan;30(1):19-34.
4.      Cooperstein R,  Sacro Occipital Technique.  Chiropractic Technique.  Aug 1996; 8(3): 125-31.

Introduction: Symptoms of temporomandibular/craniomandibular disorders (TMD/CMDs) vary but often involve severe pain in the jaw musculature, severe pain or difficulty when opening the mouth and chewing, headaches, and ear pain. In conditions where a chiropractor or dentist has reached a therapeutic impasse with a patient’s TMD/CMD, cotreatment may be indicated. This article presents two case reports demonstrating how cotreatment may proceed initiated by a dental and/or a chiropractic referral.

Case Report: Case #1 Chiropractic to Dental Referral, The Assessment: A 41 year old female presented at my office referred by a chiropractor for her chronic TMJ dysfunction. The patient described that she has had a history of painful and limited chewing and the first time she started having TMJ symptoms, approximately 5 years prior, she was unable to close her jaw.  She had been to a dentist and was wearing a dental nightguard but reported she was still “grinding” her teeth for years.  She also had concomitant neck and shoulder tension.

The patient presented with a sacroiliac hypermobility syndrome (category two), restricted intersegmental motion at C2/3, increased suboccipital muscle tension and restricted flexion at the C0/1 junction.  Sphenobasilar range of motion found imbalance in flexion/extension testing congruent with a chronic forward head posture (FHP).

Case #2 Dental to Chiropractic Referral, The Assessment: 43 year old male was referred for chiropractic care by his dentist to facilitate any pelvic, cervical and cranial involvement secondary to a full mouth reconstruction.  The dental work used a (maxillary) Invisoline for orthodontic modifications along with occlusal modifications using a (mandibular) dental splint maintaining functional changes to the patient’s body.

The SOT TMJ and cranial diagnostic strategies [1,2] were used for analysis and treatment. The patient’s diagnosis was a category two with right hip dysfunction, cervical myofascitis, and TMJ sprain on left side with some dysfunctional joint translation. Following treatment an Aqualizer was used to limit any dental occlusion and the, patient was seen by the dentist.

Intervention: The treatment involved SOT management of the patient’s presentation, while relating to TMJ dysfunction, was focused on whole body dynamics and function. The treatment with these two patients had similar aspects in that they both presented with sacroiliac joint hypermobility syndrome (category two), cervical intersegmental restricted motion, and needed craniomandibular balancing therapeutic interventions. SI joint treatment was performed with the patient supine, reducing pelvic torsion and stabilizing the posterior SI joint.  Exercises were given to prevent asymmetry of hip joint function as well as hip extension exercises to stimulate ligament integrity.

Cervical treatment involved myofascial balancing methods and cervical stairstep procedures to improve intersegmental cervical function.  SOT sutural cranial procedures worked with improving symmetrical motion of the craniomandibular muscles.  Craniomandibular treatment focused on improving TM joint translation, balance, and reduced joint crepitus along with reduced tension and pain to palpation. Motion at cranial suture and related dural tension was reduced which was noted by the patient’s greater relaxation and improved TM function.  When indicated, home exercises were given to both patients to help improve TM joint translation and/or gaining awareness to relax jaw, tongue, and suboccipital muscle tension.

Results: The essential findings in both cases showed reduced pain in TMJ function and/or symmetrical joint translation without crepitus. General relaxation in cervicocranial and craniomandibular musculature was noted by the patient, chiropractor and dentist. The focus was having the patient gain independence from chiropractic/dental care with reduced discomfort and increased function.

Discussion: With a subset of patients body distortions ascend from the feet, pelvis, spine, and neck to affect TMJ dynamics affecting dental occlusion, condylar position, and airway space. With another subset of patients patterns of body distortions descend from TMJ dynamics affecting dental occlusion, condylar position, and airway space. A main obstacle for chiropractic/dental cotreatment is the lack of awareness and knowledge of each other’s professional treatment and diagnostic focus as well terminology. Research studies have noted a relationship between ascending and descending relationships associated with CMD/TMD and postural dysfunctions.

Evaluating 45 asymptomatic subjects Sakaguchi et al concluded that:

“1.     Body posture was more stable when subjects bit down in centric occlusion.

2.      Changes in body posture affected occlusal force distribution.

3.      Altering body posture by changing leg length shifted the occlusal force distribution to the same side that had a heel lift [3].”

“In a clinical setting, when dental occlusion is developed and finished, body posture should be taken into account [3].”  ”If a patient has a length discrepancy, hip rotation or any other problem altering body posture, occlusal contacts may differ as the patient stands up and starts walking [3].”

One mechanism for the observed changes may be a relationship between how TMJ occlusion, head position and body posture relates to the body’s natural neurological visual/vestibular righting mechanism [4]. Currently there are no Dental/Chiropractic TMD “Need for Co-treatment” outcome assessment forms evaluated for reliability or validity.  The Steigerwald -Maher form may offer the chiropractic profession some referral guidance and the Blum – Globe form [5] may offer the dental profession some referral guidance.

Conclusion: While these two cases illustrate how the chiropractic and dental fields can work together for successful treatment outcomes, there is a need to determine what subsets of patients may fit this model.

References:

1.     Chinappi AS, Getzoff H. A New Management Model for Treating Structural-based Disorders, Dental Orthopedic and Chiropractic Co-Treatment. Journal of Manipulative and Physiological Therapeutics. 1994; 17: 614-9.
2.     Blum CL. Chiropractic and Dentistry in the 21st Century: Guest Editorial.  The Journal of Craniomandibular Practice. Jan 2004; 22(1): 1-3.
3.     Sakaguchi K, Mehta NR, Abdallah EF, Forgione AG, Hirayama H, Kawasaki T, Yokoyama A. Examination of the relationship between mandibular position and body posture.  Cranio. 2007 Oct;25(4):237-49.
4.     Gangloff P; Louis JP; Perrin PP. Dental occlusion modifies gaze and posture stabilization in human subjects. Neurosci Lett. 2000 Nov 3;293(3):203-6.
5.     Blum CL, Globe G. Assessing the Need for Dental – Chiropractic TMJ Co-The Development of a Prediction Instrument. Journal of Chiropractic Education. Spr 2005;19(1).

Introduction: This case report investigates the therapeutic benefits of utilizing the sacral block (wedge) to balance sacrospinal and cranial dural tensions ultimately assisting to balance sacral nutation. A relationship between intrathecal tensions, Milgram’s sign, and sacral block technic is also explored. Sacral block technique was initially developed by M. B. DeJarnette in 1976 and was used to treat, when applicable, any related cranial dural imbalance, and was termed, “cranial vault balancing technique.” Since Milgram’s sign is related to intrathecal pressure imbalance, leg lift testing was incorporated to evaluate the effectiveness of the sacral block technic. While reduced sacral nutation is commonly associated with SI fixation (category one) [1], DeJarnette also found some restriction to sacral nutation with SI joint hypermobility (category two).

Methods: The arm fossa test is an evaluation tool developed by DeJarnette to differentiate between SI joint fixation or hypermobility [2]. He found that SI joint hypermobility, with altered sacral nutation, at the full inspiration or expiration phase of pulmonary respiration, would cause inhibited response during the arm fossa test. With the patient supine the sacral block or wedge would be placed under the sacral apex when there was an inhibited response on inhalation to the arm fossa test and under the sacral base when there was an inhibited response on exhalation. Clinically a relationship was found relating to the patient’s inability to lift their legs when supine, an inhibited arm fossa test with a specific phase of respiration, and improvement of these indicators with sacral block technic.

Case Report: Assessment: A 75 year old male patient who had received chiropractic care since 1989 noted that in mid 2006, his gait and balance started to deteriorate which was of concern since he had a history of diabetic neuropathy in the lower extremities. In early 2007 he was seen for treatment and physical examination findings noted the patient had a positive Milgram’s Test and was unable to lift his legs in a supine position.

Treatment/Intervention: During 2007 he was treated approximately 5 times using the sacral block technic and gradually responded to treatment, had improved gait/balance, and was able to lift his legs in a supine position. Three months later, July 2007, the patient returned with inability to lift his legs in the supine position along with some decreased gait/balance functioning. He was adjusted again with the sacral block technic, the gait/balance improved and he could lift his legs. Subsequently while he suffered from some dizziness and knee pain with over exertion, his gait and stability remain improved through the spring of 2008.

Discussion: Sacral nutation involves anterior and posterior cyclic rotation (rocking) of the sacrum focusing at the anterior sacroiliac (SI) joint [3]. Nutation occurs secondary to pulmonary respiration and during walking and is postulated to assist with cerebrospinal fluid mixing from the lumbopelvic cistern cephalward. SI joint fixation secondary to pelvic torsion [4] or any factor that alters sacral nutation would then purportedly adversely affect CSF circulation and leading to some degree of CSF stagnation and resultant catabolic build-up in the sacrospinal subarachnoid space. The cranial-sacral dural system continues from the periosteal/meningeal cranial dura to the spinal canal ending within the sacrum at the 2nd sacral segment. This dural system also has various myoligamentous connections (Trolard’s Ligament, Thoracolumbar Ligaments of Hoffman, and ligamentum flava), which maintain balanced intrathecal tensions. Any factors limiting sacral nutation would likely alter dural tensi ons creating ascending influences on the spinal dural space and adjacent spinal subarachnoid space where CSF circulates [5].

Conclusion: The sacral block technic may be an effective tool for treatment of conditions associated with CSF stagnation secondary to reduced sacral as well as patients with a positive Milgram’s sign. Further study is necessary to evaluate greater clinical correlations to determine the effectiveness of the sacral block technic. While this patient had a significant response to treatment further research is indicated to determine what subset of patients would best respond to this care. Since the treatment represents a low force, low risk intervention further study to evaluate its benefit would be warranted.

References:

1. Blum CL, Sacro-Occipital Technique’s “Category Two”: A Remedy for Fixated Thinking. Dynamic Chiropractic. Sep 1, 2006; 24(18).
2. Hestoek L, Leboeuf-Yde C, Are chiropractic tests for the lumbo-pelvic spine reliable and valid? A systematic critical literature review. Journal of Manipulative and Physiological Therapeutics. May 2000;23:258–75.
3. Vleeming A, Pool-Goudzwaard AL, Hammudoghlu D, Stoeckart R, Snijders CJ, Chris J, Mens JMA. The Function of the Long Dorsal Sacroiliac Ligament: Its Implication for Understanding Low Back Pain. Spine. Mar 1996;21(5):556-62.
4. Cooperstein R, Lisi A. Pelvic Torsion: Anatomic Considerations, Construct Validity, and Chiropractic Examination Procedures. Topics in Clinical Chiropractic. Sep 2000; 7(3): 38-49.
5. Farmer JA, Blum CL. Dural Port Therapy. Journal of Chiropractic Medicine. Spr 2002; 1(2):1-8.

Introduction: Is sacroiliac (SI) joint laxity associated with pregnancy and delivery cause objective findings of an sacro occipital technique (SOT) category two pelvis?  Pelvic insufficiency or SI ligament laxity, which can occur during pregnancy “is defined as a condition with pain at the pubic symphysis and/or the sacroiliac joint developing in connection with pregnancy or delivery [1].” The frequency is 7.6-18.5 per 1000 deliveries. The incidence is increased in multiparae and women with occupations, which strain the back. Recurrence occurs in 41-77%. The condition appears for the first time usually in the 5th-8th months of pregnancy. The majority of patients recover shortly after delivery but in some a condition of prolonged pain persists [1].”

In a study by Mens et al they found that,” about 45% of all pregnant women and 25% of all women postpartum suffer from pelvic girdle pain and/or low back pain (PLPP) [2].” They concluded that “during the last months of pregnancy and the first 3 weeks after delivery, motion of the pelvic girdle joints is 32-68% larger in patients with PLPP than in healthy controls [2].”  Ultimately their “findings support the idea that enlarged motion is one of the factors that causes PLPP and justifies treatment with measures to reduce this motion [2].”

SOT describes a category of PLPP associated with increased posterior SI joint motion or ligamentous laxity called category two [3].  “Since load transfer from spine to pelvis passes through the sacroiliac (SI) joints, effective stabilization of these joints is essential. The stabilization of the SI joint can be increased in two ways. Firstly, by interlocking of the ridges and grooves on the joint surfaces (form closure); secondly, by compressive forces of structures like muscles, ligaments and fascia (force closure) [4].”

One hundred and three pregnant women age range from 21-32 years old were seen at this clinic from 1979-83.  The majority of the patients were referred to this clinic by nearby Bradley and Lamaze Birthing Classes and La Leche League facilities.  The preponderance of the patients (75%) began their evaluation and treatment in their third trimester with the rest (25%) began their evaluation and treatment in their first two trimesters.

Methods: Patients were evaluated via SOT diagnostic protocol, which included the SOT arm fossa test [5], increased unilateral or bilateral iliopsoas tension, palpation for pelvic torsion, leg length differentials, and Moiré contour photography. Frequency of evaluations was generally monthly during the first trimester, bi-weekly during the second trimester, weekly during the final trimester.  This method of evaluation and treatment was a standard procedure at this office during that period of time. Post delivery visits were 2-3 times per week until their arm fossa test was negative.

Treatment with Category two blocking was performed in the presence of a positive arm fossa test (AFT+) with the patient supine, the superior block placed on the side of the posterior ilium, and on the contralateral side a block placed through the acetabulum superiorward at 45 °, until the arm fossa test was negative (AFT-)  (less than two minutes). The goal of the process was to “clear” the category two before the delivery and evaluate after delivery for the presence of category two indicators of arm fossa test positive, leg length differential and pelvic torsion [3].

Results: Using SOT’s arm fossa test as a method to evaluate clinically active category two or sacroiliac joint laxity, a large percentage of the patients (95%) had AFT+ findings, with 5 of the 103 patients having an AFT-.  Moiré contour photography showed posterior ilium rotation of the pelvis in all cases of AFT+ however the posterior rotation of the pelvis was not always on the short leg side upon supine evaluation.  Of the 98 patients who had an AFT+ with the treatment all but 15 became AFT- before delivery.  Of the 98 patients with an AFT+ ten patients never achieved an AFT- status after delivery.  AFT- patients showed pelvis rotation on Moiré and short leg on supine evaluation in the same proportions as the AFT+ patients. Post delivery AFT- was achieved in 5-7 visits, which was more than the clinic’s average of 3-5 visits for AFT- in non-postpartum patients. Women who became ambulatory sooner and walked also had better return to AFT- than the patients who did not walk as soon.  Women were more prone to re-injury (return of AFT+) if they did not walk daily soon after delivery.

Discussion: The natural laxity of the SI joints occurs in preparation for birthing process and while essential for delivery this condition can sometimes lead to a loss of juxtaposition of the pubic symphysis and sacro-iliac joints. With the high percentage of participant’s delivery leading to SI laxity it is reasonable to assume a subset of pregnant patients may likely have a category two presentation during pregnancy and delivery. SOT practitioners have used the AFT for 4 decades to evaluate posterior SI joint laxity and pelvic torsion.  The reliability and validity of the AFT was discussed by Hestœk et al [5], and “results from the different reliability studies varied widely with some evidence favoring the validity of the arm-fossa test … [5]”

Category two supine block placement facilitates both form and force closure of the SI joint by reducing pelvic torsion and compressing the posterior SI joint. The compression helps reduce the secondary swelling in the joint capsule allowing the joints to come into better juxtaposition. Of interest in the county where this retrospective case series took place during the era (1979-1983) over 30% of pregnancies ended in cesarean section. Of the women (n=103) in this study only 3% ended in cesarean section. Limitations to this study involve the reliability and validity of the arm fossa test [5] and that the patients were relatively young, 21-32 years old. No control group was used and the majority of patients were receiving training with Lamaze, Bradley, and La Lechi League which suggests patients familiar with wellness behavior and pregnancy.

Conclusion: Of significance is the relationship between category two arm fossa test findings and pregnant patients.   Greater study into the arm fossa test is needed to determine its accuracy in determining SI joint laxity in pregnant patients as well as the use of pelvic blocks to reduce pelvic torsion and improve form and force closure of the SI joints.

References:

1.      Ostergaard M, Bonde B, Thomsen BS. [Pelvic insufficiency during pregnancy. Is pelvic girdle relaxation an unambiguous concept?] [Article in Danish] Ugeskr Laeger. 1992 Dec 7;154(50):3568-72.
2.      Mens JM, Pool-Goudzwaard A, Stam HJ. Mobility of the pelvic joints in pregnancy-related lumbopelvic pain: a systematic review. Obstet Gynecol Surv. 2009 Mar;64(3):200-8.
3.      Getzoff H. Sacro Occipital Technique Categories: a System Method of Chiropractic. Chiropractic Technique. May 1999; 11(2): 62-5.
4.       Pool-Goudzwaard AL, Vleeming A, Stoeckart R, Snijders CJ, Mens JM. Insufficient lumbopelvic stability: a clinical, anatomical and biomechanical approach to ‘a-specific’ low back pain. Man Ther. 1998 Feb;3(1):12-20.
5.      Hestœk L, Leboeuf-Yde C, Are chiropractic tests for the lumbo-pelvic spine reliable and valid? A systematic critical literature review, Journal of Manipulative and Physiological Therapeutics May 2000;23:258–75.