Overview of Osteopathic Manipulative Treatment: Muscle Energy Procedure – Sacral Dysfunctions
Osteopathic manipulative treatment is a type of manual therapy used by healthcare providers to find and treat the root causes of back pain. This treatment utilizes methods such as muscle energy techniques (METs) that focus on sacral dysfunctions, with the aim of relieving back pain symptoms. The sacrum is triangular-shaped bone at the base of your spine that plays a key role in back health and movement.
Low back pain is a common issue and it’s often hard to find the exact cause and treat it effectively. In fact, studies show that a clear cause cannot be found for about 85% of people who suffer from low back pain. Medical schools usually teach that most back pain relates to issues with muscles, bones, and joints. But since it’s rare to pinpoint an exact cause, ongoing pain can limit activities and greatly reduce a person’s quality of life. METs have been key in treating structural issues linked to low back pain, particularly when connected to sacral dysfunction.
The muscle energy techniques (METs) were initially developed by Dr. Fred Mitchell in the 1950s, based on his understanding of the pelvic movements. METs are considered a direct, active treatment as patients are often positioned in a way that requires them to move and create a force. Using this technique, the patient would be positioned in a way that they apply force in a direction that allows freedom of movement.
There are different METs principles, one of them, and the most widely used, is post-isometric isolation, which leads to relaxation of the opposite muscle and this effectively treats soft tissue limiting movements and mobilizes joints. This process can help reduce pain and improve blood circulation. Also, abnormal movement in the sacroiliac joint (the joint between the sacrum and the pelvis) can lead to various types of dysfunctions that may contribute to pain. This article explains how to diagnose and correct these dysfunctions using METs.
Anatomy and Physiology of Osteopathic Manipulative Treatment: Muscle Energy Procedure – Sacral Dysfunctions
The muscles in our body work in four different ways. One, they can lengthen despite being contracted due to an external force; this is known as isolytic contraction. Two, they can shorten during contraction, which we call concentric contraction. Three, they can contract without moving closer together, referred to as isometric contraction. Lastly, they can lengthen while contracting, a process known as eccentric contraction.
Your muscle is full of tiny structures called spindles, each made up of a large outer muscle fiber wrapped around 3 to 12 smaller inner fibers. These outer fibers are controlled by alpha (α) motor neurons, and the inner ones by gamma (γ) motor neurons. They are also connected to sensory fibers that control muscle tension. A key part of these fibers is the Golgi tendon organ, which helps prevent the muscle from contracting too much. This is particularly critical to a technique called ‘muscle energy technique’ or MET.
MET with post-isometric relaxation is a common method. It involves contracting the muscle against a barrier created by the doctor. This activates the Golgi tendon organ, which in turn relaxes the muscle via the Ia fibers, allowing it to be stretched further in its relaxed state.
The sacrum is a bone at the bottom of our spinal column. It’s shaped like a triangle and helps move our body smoothly when we walk. It connects to the bottom of our spine at the top, and to the coccyx (tailbone) at its base, with its sides attached to the ilium (a part of the pelvic bone). This makes it easy to touch and find for medical professionals.
The sacrum and the sacroiliac joint, where the sacrum and ilium meet, can sometimes cause lower back pain. This joint is shaped like an ‘L’ and is filled with a special fluid. It stays stable thanks to ligaments, tendons from surrounding muscles, and the thoracolumbar fascia which is a type of connective tissue.
The sacrum, which forms a kind of inverted triangle, is easy to locate by feeling just below the two bumps on either side of your lower back, known as the posterior superior iliac spines (PSIS). The bottom of the sacrum is called the inferior lateral angle (ILA) and can be located by tracing the curve of the sacrum with your hand.
Although once thought to be immobile, recent studies have shown that the sacroiliac joint actually moves in complex ways. The sacrum has three main points of movement – the superior, middle and inferior transverse axes. These points allow the sacrum to move during different activities like breathing, maintaining posture, and walking. The middle transverse axis, in particular, helps transfer weight and facilitate smooth movement when walking.
The term ‘nutation’ refers to the forward and downward movement of the sacrum, while ‘counternutation’ refers to its backward and upward movement. These movements are usually felt during breathing or bending of the lower back. Understanding these movements of the sacrum in relation to the lumbar spine (lower back) aids doctors in diagnosing and treating back problems.
Why do People Need Osteopathic Manipulative Treatment: Muscle Energy Procedure – Sacral Dysfunctions
MET, short for Muscle Energy Technique, is a type of treatment usually used to help with lower back pain that’s related to issues with the sacrum, a bone at the bottom of your spine. Because nerves in your pelvis, sacrum, and nearby areas are all connected, issues in one area can affect others. This means that problems with your sacrum can affect your parasympathetic nervous system, which is part of the nervous system that helps control your body’s functions when it’s at rest. This can have an impact on your large intestine and genitourinary systems, which involve both the urinary and reproductive organs. As a result, conditions like constipation and painful menstrual periods, also known as dysmenorrhea, could potentially improve by treating problems with the sacrum.
When a Person Should Avoid Osteopathic Manipulative Treatment: Muscle Energy Procedure – Sacral Dysfunctions
Muscle energy techniques (METs) are generally considered safe and can be done with very few problems. METs involve using a controlled, steady force to stretch a tight muscle, which usually poses few risks and is tolerable for patients who are in acute pain. However, if a patient has torn muscles, broken bones in the area being treated, or torn ligaments in the spine or vertebral joints, METs should be done carefully or not at all. Moreover, since METs need the patient to follow the therapist’s instructions effectively, the patient should be able to understand and follow instructions properly.
Equipment used for Osteopathic Manipulative Treatment: Muscle Energy Procedure – Sacral Dysfunctions
A simple flat surface, like a hospital bed or a padded massage table, is good enough to carry out muscle energy techniques (MET). Having a table that can be adjusted in height makes it easier for the patient to get into the right position and also lessens the physical stress on the healthcare provider who is giving the treatment.
Preparing for Osteopathic Manipulative Treatment: Muscle Energy Procedure – Sacral Dysfunctions
Diagnosing issues with the sacrum, a triangular bone at the base of the spine, requires multiple steps and is unlike the diagnosis of other spinal issues. This is due to the possible occurrence of ten different types of irregularities or untreated conditions. The diagnosis includes both stationary and movement-based tests.
One very important movement-based test for sacrum irregularities is the seated flexion test. In this test, the patient sits down, and this action secures their pelvis. This allows the doctor to observe the movement of the sacrum without interference from the pelvic bones. The test is performed with the patient sitting flat on the floor. The doctor then watches the movement of the sacrum as the patient bends forward. The side of the sacrum that moves the most upwards is identified by the rear movement, indicating a positive test. If the side of the sacrum associated with the irregularity cannot move efficiently, it will pull the pelvis upwards during bending. If an irregularity occurs along a slanted line on the sacrum, it is considered a torsion.
Another crucial movement-based test is the spring test and the sphinx test. In the spring test, the patient lies down flat on their stomach, and the doctor applies a slow downward pressure through the junction between the lower back and the sacrum. A positive result, which suggests restricted movement, is indicated by a hard stopping point. Similarly, the sphinx test, where the patient assumes a sphinx-like position, also helps to identify similar findings. The doctor observes the dimple or inferior lateral angles (ILAs), the lowest point on each side of the sacrum. If asymmetry is corrected during this test, the patient likely has forward or flexed sacral dysfunction; if the landmarks become asymmetrical or cause increased pain, they likely have a backward sacral dysfunction, or extension dysfunction.
For stationary or static diagnosis, doctors need to feel the sacral dimple (base of the sacrum) which is located a finger-width from the midline and lower than the highest points at the back of the pelvic bone and the ILA.
When there is a single-sided sacral dysfunction – either flexed or extended – depending on the depth of the sacral dimple (or position of the sacral base) and the movement during the seated flexion test. The irregularity is named for the side that showed a positive seated flexion test.
If the patient shows an irregularity known as sacral torsion dysfunction, the deep dimple and the back ILA are on opposite sides. The sacrum can show either an anterior or a posterior torsion. The doctor may perform either the sphinx or the spring test to determine this.
Issues with both sides of the sacrum are rare and often missed. The patient usually reports pain in the area where the lower back meets the sacrum and the iliosacral joint. The patient will show equal dimples, symmetrical ILAs and a negative seated flexion test. The sphinx and spring tests results depend on whether it is a case of bilateral sacral extension or flexion.
How is Osteopathic Manipulative Treatment: Muscle Energy Procedure – Sacral Dysfunctions performed
This article will look at a technique called muscle energy techniques (MET) with post-isometric relaxation, used to treat conditions related to the sacrum and sacroiliac (SI) joint in your back. This technique is a bit complicated because of the position we need the patient to be in. To make sure we’re moving the right parts in the right way, we sometimes also need to focus on the 5th lumbar vertebra (L5).
Here are the types of treatments using these muscle energy techniques:
Anterior Torsion
In what we call the Sims position, the patient is on their belly, with the lower body bent to one side. The side with the issue faces the table. For example, if the left side is the problem, the patient lays on their left side. The body is twisted to limit movement in the spine above the L5 level.
Then, the hips and legs are bent till the movement is only at S2 (that’s a point where the sacrum moves against the pelvic bones called ilia). The doctor pulls both legs down towards the table to engage the barrier, that’s the point where movement starts. The patient is told to try to lift both their feet while the doctor holds them down for about 5 seconds. After that, the patient relaxes, the hips are bent even more and the feet are lowered. The cycle is repeated 3 to 5 times. After the treatment, the patient’s condition is evaluated again.
Posterior Torsion
For this treatment, the patient is in a sideways position with the problematic side facing the table and knees bent. The doctor rotates the patient’s upper body backwards to limit movement in the spine above the L5 level. The knee on top is bent till the movement is felt at the S2 level.
The leg bottom leg is stretched while the top leg is dropped off the table. The doctor then lowers the upper leg until he can sense movement under his monitoring hand. The patient tries to lift their leg while the doctor applies an equal and opposing force. After 5 seconds, the patient relaxes, the hip is extended even more and brought towards the floor. This process is repeated 3 to 5 times and the patient’s condition is assessed again.
Unilateral Flexion and Extension
Depending on the diagnosis, the patient is placed face down with the leg on the identified side slightly moved out and turned inward. This allows movement at the sacroiliac joint while keeping the hip joint still. The doctor applies force to the sacrum, following its movement during the breathing cycle of the patient. This movement is repeated 3 to 5 times and then the movement of the sacrum and other conditions are reassessed.
Bilateral Flexion and Extension
The patient is positioned similarly as in unilateral flexion and extension, but with both legs moved out and turned inward. Depending on the condition, the doctor applies force to the center of the sacral base or the tip of the sacrum. For bilateral flexion, force is applied to the tip of the sacrum during inhalation. For bilateral extension, force is applied to the sacral base with inhalation.
Possible Complications of Osteopathic Manipulative Treatment: Muscle Energy Procedure – Sacral Dysfunctions
If you’re going through a treatment known as Muscle Energy Technique (MET), it’s important to know that you might feel some muscle soreness and tiredness afterward. The doctor would likely advise you to drink more water after the treatment to help counter these effects. It’s also crucial to not use too much force during the treatment. If too much force is used, the body might start using larger muscles, which can interfere with the treatment that’s supposed to target smaller, specific muscles.
In order to avoid using too much force during what’s called post-isometric relaxation (a part of the treatment where you relax the muscle after tensing it), you’ll be coached to resist with just the right amount of force to focus on the treated area. This helps ensure that the treatment is as effective as possible.
What Else Should I Know About Osteopathic Manipulative Treatment: Muscle Energy Procedure – Sacral Dysfunctions?
Sacral dysfunction is a condition that often results in back pain and discomfort, causing many people to seek medical help. Sacrum here refers to the large, triangular bone at the base of your spine, just above your tailbone. Osteopathic techniques such as Muscle Energy Techniques (MET) are non-drug treatments that help in pain relief and rectifying these muscle and joint issues in the mid-back (thoracic spine). This makes the joints more movable and flexible.
Having a healthy functioning sacrum is crucial for a normal walking pattern (gait); thus rectifying sacral problems can improve walking and lessen the risk of injuries due to instability. Treatment of the sacrum can also help alleviate pain in the sacroiliac joint (the joint connecting the base of the spine with the pelvis) which is responsible for lower back pain in about one in four patients. Consequently, resolving these issues without surgery or medication can greatly enhance well-being and mobility.
Physicians should also consider the possibility of nerve-related implications of sacral dysfunction. The nerves that control some functions of your lower stomach and bladder (parasympathetic splanchnic nerves) start from the sacrum. Some theories suggest that by treating sacral problems, it might improve conditions relating to the lower stomach, uterus, and bladder functions.
If the physician deems a specific technique (high-velocity, low-amplitude technique) more suitable for treating the sacrum, MET can be employed first to loosen the soft tissues and improve the treatment’s effectiveness. It can also be beneficial in resolving excessive muscle tension before applying other techniques that release tension in the muscles and soft tissues (myofascial release techniques).
It’s essential to note that sacral dysfunction is often caused by issues in other parts of the body. To ensure a comprehensive treatment, other nearby areas should be examined and treated before addressing the sacrum. Parts that might affect the sacrum’s placement include the last of the spine’s vertebra known as L5 and the hipbones or leg length differences.