Continuing Education Activity
Osteopathic manipulative medicine utilizes many techniques to diagnose and treat structural dysfunctions. Sacral dysfunctions identified in patients presenting with low back pain can receive treatment with muscle energy providing patients with relief of their symptoms. This activity reviews muscle energy techniques for treating sacral dysfunctions and highlights the role of the healthcare team in evaluating and treating patients with back pain related to sacral dysfunctions.
- Review the anatomy and physiology of the sacrum.
- Describe osteopathic manipulative techniques to diagnose and treat sacral dysfunctions.
- Explain the role of osteopathic manipulative treatments in the management of acute low back pain.
- Outline the importance of collaboration and communication amongst the interprofessional team to improve outcomes for patients affected by low back pain secondary to sacral dysfunctions.
Osteopathic manipulative medicine involves an assortment of manual techniques and is utilized by many osteopathic physicians to treat a wide range of conditions. Low back pain is a common complaint encountered by many clinicians and proves to be challenging to diagnose and treat. Studies have shown about 85% of patients presenting with low back pain complaints are unable to be provided with a precise diagnosis for their symptoms. As specific etiologies are less commonly identified, continuous pain leading to limitations in activities results in decreased quality of life for patients. Muscle energy techniques (MET) have been an essential tool in correcting structural restrictions leading to low back pain, especially related sacral dysfunctions.
These techniques were initially developed by Dr. Fred Mitchell, Sr. and later refined by Dr. Fred Mitchell, Jr., both osteopathic physicians. MET maneuvers employ an isotonic contraction produced by the patient to engage the dysfunction and is restricted by the physician with a counterforce. Each contraction is repeated three to five times with a relaxation and stretch phase in between as the physician moves the patient in a controlled motion until meeting the next barrier. The isometric contraction creates a reciprocal inhibition and relaxation of the antagonistic muscle, effectively treating soft tissue restrictive barriers and mobilizing joints. This process, in turn, reduces pain and improves circulation. Sacral motion within the SI joint can produce several dysfunctions: anterior torsion, posterior torsion, and unilateral flexion or extension dysfunctions. This article will discuss how to diagnose such sacral dysfunctions and describe muscle energy techniques used to correct such dysfunctions.
Anatomy and Physiology
The sacrum and its function relative to the sacroiliac joint (SIJ) has been identified as a source of low back pain since the early 20 century. The SIJ is considered a diarthrodial joint, containing synovial fluid and encompassed by a fibrous capsule. The stabilization of the SIJ is provided by ligamentous attachments, tendinous attachments from the gluteus maximus and piriformis muscles, as well as the thoracolumbar fascia extending from the latissimus dorsi. The sacrum originates from five individual vertebrae that fuse by ossification in the first year of life. The sacrum forms an articulation with the fifth lumbar vertebra at its superior surface, inferiorly with the coccyx, and lateral articulations with the ilium. This anatomical relationship is vital for palpation and location of sacral landmarks.
The sacrum has an inverted triangle wedge shape, with the widest portion forming the sacral base superiorly and the apex inferiorly towards the coccyx. The sacral base can be located by palpating just inferomedial to the posterior superior iliac spines (PSIS). The most inferior aspect of the sacrum forms projections known as the inferior lateral angle (ILA). This structure is identifiable by following the convex dorsal surface of the sacrum with the palm of the hand or pads of the fingers until there is a drop-off just superior to the coccyx. These landmarks are useful in testing sacral motion and identifying dysfunctions.
Initially, the belief was that the sacroiliac joint was immobile; however, studies have revealed simultaneous rotation and translation in a sagittal plane. The sacral base moves anteroinferior about a superior and medial transverse axis in a motion known as nutation. When the sacral base moves posterosuperior about the same axis, this is called counternutation. Nutation can be produced during the exhalation phase of respiration, as well as during the extension of the lumbar spine. Counternutation, conversely, will occur during inhalation or lumbar flexion. The clinician can palpate these motions by placing their index fingers just inferior to the PSIS and the thumbs placed over the sacral base monitoring for anterior or posterior translation or the sacral base during truncal extension or flexion respectively.
Studies have also revealed rotation of the sacrum and SIJ about oblique axes, which is responsible for developing sacral dysfunctions such as torsions. The right oblique axis runs from the right sacral base diagonally through the left ILA, whereas the left oblique axis runs from the left sacral base through the right ILA.
With the extensive network of fasciae, muscles, and ligaments supporting and interconnecting skeletal structures, the movement of the sacrum about these axes has a strong relation to the lumbar spine. The rotation of the fifth lumbar vertebra, which sits directly superior over the sacral base, causes rotation of the sacrum as a unit in the opposite direction over one of the oblique axes. Side-bending of the fifth vertebrae engages the oblique axis on the same side, indicating the oblique axis on which the sacrum is rotating. By understanding the anatomical relationships between structures of the sacrum and SIJ, it is possible to diagnose sacral dysfunctions and treat them accordingly.
MET is most commonly used for treating low back pain complaints associated with sacral dysfunctions. However, due to the close relationship between the sacral plexus innervation in the pelvis, the sacrum, and surrounding structures, dysfunctions may also lead to changes in parasympathetic tone, affecting the large intestine and genitourinary systems. Therefore, conditions such as constipation and dysmenorrhea may also find benefits from the treatment of sacral dysfunctions.
Muscle energy is relatively safe and has few complications. As it is utilizing a controlled, equal, and opposite force to lengthen a contracted muscle, it poses few risks and proves to be tolerable for patients in acute pain. However, muscle energy techniques should be avoided and used with extreme caution if there is a concern for muscle ruptures or tears, fractures in the treated region, or spinal or vertebral joint ligament rupture.
A flat surface, such as a hospital bed or massage table with padding is adequate for performing MET. The ability to adjust the height of the table allows for ease of positioning the patient, and less strain on the clinician providing the treatment, however, is not required.
The initial assessment for sacral dysfunctions begins with an evaluation for sacral motion restrictions by performing the seated flexion test. With the patient seated, this stabilizes the ileum, allowing in the assessment of sacral motion without the influence of the innominate bones. The seated flexion test is performed with the patient in a seated position with feet flat on the floor. The clinician monitors the motion with their thumbs just inferior to the patient’s PSIS as the patient flexes forward. The side of the dysfunction is noted by the PSIS that moves the most superior or cranial, indicating a positive seated flexion test. The rotation of the sacrum is also over the oblique axis opposite the side of the dysfunction. Therefore, if the test is positive with the left PSIS moving more cranial, the sacrum is rotating on the right oblique axis.
After assessing the side of the sacral dysfunction, palpation over the sacral base and ILAs will help to determine which portion is more posterior when comparing sides. Place the pads of the thumbs over the sacral base and assess for any asymmetry between thumb heights and notate which side is more posterior (or shallow). Then palpate over the dorsal surface of the sacrum, moving inferiorly until there is a drop-off. This last portion, just superior to the coccyx is the ILA. Again, place the pads of the thumbs along the inferior margin of each ILA and compare for asymmetry, noting which side appears to be more inferior or posterior. To treat the dysfunction appropriately, the clinician must understand the findings from the testing discussed above and name the dysfunction.
Diagnosis and Nomenclature
Anterior torsions are physiologic and occur during the walking cycle; however, they can become dysfunctional when restrictions develop. Nomenclature for anterior torsions involves rotation of the sacrum in the same direction as the oblique axis originates. They are either left rotations about the left oblique axis, or right rotation over the right oblique axis. Again, the side of the positive seated flexion indicates the dysfunctional side and tells you the rotation is on the oblique axis of the opposite side. Therefore, a positive seated flexion test on the left indicates rotation on the right oblique axis. If both the sacral base and ILA on the right are more posterior compared to the left, the sacrum is then rotated right about the right oblique axis.
Bending, twisting, and lifting motions are the most common causes of posterior torsions. These dysfunctions are again identified by performing the seated flexion tests and palpating the sacral base and ILAs. Posterior torsions are named as such due to the sacrum being rotated posteriorly in the same direction as the dysfunctional side over the opposite oblique axis. So if the seated flexion test is positive on the right side, indicating rotation on a left oblique axis, and the sacral base and ILA are posterior on the right side, this represents a right rotation over the left oblique axis.
Unilateral flexions or extensions result from a loaded, unbalanced side-bending motion of the trunk. Unilateral dysfunctions are easily identifiable when palpation over the sacrum reveals a posterior sacral base and posterior ILA on opposite sides. Unilateral flexions will have an anterior sacral base on the same side as the positive seated flexion test, with a posterior ILA on the opposite side. Unilateral extensions, on the other hand, will have a posterior sacral base on the side of the seated flexion test with the opposite ILA noted to be posterior.
Position the patient, so they are lying on the side opposite the sacral rotation (i.e., the sacrum has rotated left, lay the patient on their right). Introduce side-bending and rotation of the lumbar spine by pulling the patient’s lower arm out from under them, engaging the restrictive barrier of the sacrum. Monitor the sacral base by flexing the thighs and localize the position at which the tissues feel the most relaxed just before reaching the barrier. Lift the feet off the table and ask the patient to pull the feet toward the table as the clinician applies an equal and opposite resistance, holding for approximately 5 seconds or until noting a change in tissue texture, then have the patient relax. After relaxing, increase the hip flexion and lift the feet more toward the ceiling to engage the next barrier. Repeat each cycle three to five times and recheck for correction of the dysfunction after completing the treatment.
Again, position the patient, so they are lying on the side opposite the sacral rotation. Pull out the lower arm to introduce side-bending and rotation of the lumbar spine to engage the sacral barrier. Extend the thighs to localize the point just before the barrier is engaged, and sacral motion is restricted. Bring the patient’s top leg forward and drop over the edge of the table. Ask the patient to lift their leg toward the ceiling as the clinician exerts the opposing force generating an isometric contraction and hold for 5 seconds or until you notice a change in tissue texture. Engage the next barrier by increasing hip extension and dropping the leg further toward the floor between each effort and repeat three to five times. Always reassess for the resolution of the dysfunction after completing the treatment.
Position the patient prone and locate the SIJ and sacral base. While monitoring the SIJ on the dysfunctional side, abduct and internally rotate the ipsilateral leg engaging the tissue barrier. Position the heel of the hand on the ipsilateral ILA (the most posterior ILA) and detect the sacral motion through the patient’s respiratory cycle. As the patient inhales, causing counternutation of the sacrum, follow the ILA anterior and cephalad. Maintain resistance at this point preventing the ILA from moving posteriorly as the patient exhales. Repeat this motion of restriction after each inhalation approximately three to five times and then reassess sacral mobility and identify any further dysfunction.
The patient again assumes a prone position. Monitor the SIJ and sacral base on the dysfunctional side while abducting and externally rotating the ipsilateral leg. The clinician is positioned at the head of the patient with the base of one hand on the dysfunctional sacral base while the other hand is placed over the ipsilateral ASIS, providing support and a counterforce. Add lumbar extension by asking the patient to come up onto their elbows. Ask the patient to take a deep breath in and upon exhalation, follow the sacral base anterior and caudad. Maintain resistance in this position as the patient inhales again, preventing the posterior motion of the sacral base. Repeat the cycle three to five times and then reassess for any residual asymmetry.
Enhancing Healthcare Team Outcomes
Muscle energy techniques provide an efficient and relatively safe route of treatment for patients presenting with a multitude of complaints, from low back pain to constipation. Interprofessional communication amongst clinicians treating patients with persistent low back pain despite pharmacologic therapy, including spinal injections and even narcotic analgesics, is particularly important as MET may be a treatment option that the healthcare team has not yet considered. Understanding the principles behind osteopathic medicine used in diagnosing structural dysfunctions, and the knowledge of the capacity for manual manipulation successfully correcting such dysfunctions, allows clinicians opportunities to treat their patients with less invasive and nonpharmacologic options, in hopes of restoring any loss of productivity and happiness in their life due to persistent pain. [Level 5]
In attempts to gain ground in the fight against the opioid epidemic, care coordination by health care professionals through referring patients for osteopathic evaluations and utilizing MET as treatment strategies will enhance patient-centered care and potentially improve favorable outcomes for patients suffering from conditions related to sacral dysfunctions.