Use of a Lumbar-Pelvic Algorithm in a Post-Ten Session

Abstract
Axial skeleton joint restrictions produce an immediate alteration in the client’s structure. These alterations can include such patterns as leg length discrepancy, changes in pelvic inclination, as well as orientation of the spinal curves. Joint restrictions also produce localized inflammation and edema, which can be experienced by our clients as pain. An array of compensations then develops in an attempt to reduce that pain.                                                                                                                                                                                   These compensations can occur throughout the body, and dramatically alter the client’s structure Joint Restriction in Structural Integration Quickly identifying and mobilizing axial joint restrictions will greatly expedite the goals of structural integration (deMahy, 2013). These types of compensations can complicate any session of a series. For example, the simplest sacroiliac restriction will produce a leg length discrepancy,
which will completely alter foundational support and grounding. A lumbar facet that will not extend can cause a posterior pelvis and a flattened lumbar curve. It is easy to see how these two compensations, individually or in combination, would affect the ability to achieve second, fifth, or sixth-hour goals.
Without addressing joint restrictions, a practitioner can waste valuable time and even an entire session
chasing compensations. Figure 1 shows the cycle of restriction and compensation.
As will be demonstrated in this article, when axial skeleton restrictions are mobilized, many of the
compensations can quickly resolve. The following post-ten case study describes how I used the
algorithm for a client who came in for a session two years after her series.
Background
During my Advanced Rolfing® training in 1989, I was introduced to the world of spinal mechanics. I
quickly saw this was going to radically change and deepen my understanding of structural integration.
Spinal mechanics can easily become complicated and confusing. I found myself spending more time trying
to figure out what was going on with my client’s spine than actually working. I realized that I needed to find or develop a tool to quickly organize specific assessments and procedures that would bring order
to the chaos and expedite that phase of a session.
In emergency rooms (ER), where speed and accuracy are essential, algorithms are used in the delivery of care. Health care algorithms are analytic tools derived from evidence-based criteria. They are used to improve quality by increasing the accuracy and specificity of assessment and treatment while also saving valuable time (Iyengar, 2009). Inspired by my work in the ER, I combed the literature for information, broke it down to digestible chunks, and applied structural integration principles to what I found.
The Lumbar-Pelvic Algorithm is designed to expedite the specific identification and resolution of joint restrictions in clients with complications in the back and lower extremities. By following the algorithm, a practitioner is able to quickly assess axial joint function without being an expert in spinal mechanics.
The algorithm begins with a simple movement test, which has a simple positive or negative result. The result directs the practitioner to a specific palpation test, which identifies the joint restriction.
The algorithm then leads to a procedure that will resolve the restriction. Then the movement test is
repeated to assure freedom of movement in the joint. (Figure 2 shows the sacral section of the algorithm.) The algorithm assessment process takes only about three to five minutes and, if no positive results are found, the practitioner is assured that joint restrictions will not interfere with accomplishing session goals.
This algorithm is divided into three sections: foundation, mobility, and locomotion. The progression of the algorithm applies the following principles: Foundation precedes mobility and mobility precedes locomotion. The foundational section assesses the pubic symphysis function and up or down slip of the innominate. These are often confused, so the algorithm guides the practitioner through a deferential assessment. Next, in the mobility section, restrictions in the lumbar spine are assessed and addressed. Once the lumbar facets are
functional, the algorithm leads into sacral assessment and treatment. Since the rotation of the innominate
on the sacrum is essential for proper gait, the locomotive section assesses and treats innominate rotation restrictions. When proceeding through the algorithm, each intervention supports the next so there is no need to repeat a test or procedure.
The progression of the algorithm applies the following principles: Foundation precedes mobility and mobility precedes locomotion.
Case Study
This case study consists of a single post-ten session in which I applied the algorithm to identify and address
lumbar, pelvic, and sacral restrictions as part of the session to stabilize and integrate the client’s structure.
I used muscle energy technique (MET) as the intervention to address the joint restrictions (Mitchell,
1995). This technique was developed by Fred Mitchell, Sr., DO in the 1950s. It is an intrinsic technique
which stimulates reflexes to temporarily override the reflexive muscle contraction(s) that restrict the joint. In the seconds that the restricting muscles release, the practitioner gently moves the joint into its functional range of motion. Since the procedure is gentle and the force is intrinsic, the client’s body does not have to negotiate the forces of high-velocity, lowamplitude adjustments. Although I used MET as the mobilization procedure in the algorithm, any direct or indirect technique could be used.
Client History
My model was a forty-year-old female yoga instructor who had completed a series of structural integration (SI) two years earlier. In the interview, she complained of right-side low back pain. She described her pain as radiating around her right iliac crest to the anterior superior iliac spine (ASIS) as well as to the back of the right calf and ball of the right foot.
Pre-Session Standing Assessment
The client stood with knees locked and weight over her heels. She had an anterior pelvic tilt and an exaggerated lumbar lordosis. The rhomboids were in a hypertonic state, decreasing the thoracic curve. Her
shoulders were elevated and head drawn forward.
She had a high level of tension in the jaw. Figure 3 shows her pre-session alignment.
Pre-Session Gait Analysis
As the client walked, she bore the majority of her weight on her left leg and avoided weight on the right. The left leg was externally rotated and the right leg was slightly internally rotated. She lifted her right leg from the waist, over-engaging her right quadratus lumborum. There was no contralateral movement between upper and lower extremities.
A video clip of the client’s pre-session gait can be viewed at http://tinyurl.com/nvpgb7l.  Applying the Algorithm
The algorithm started with a standing flexion test (Figure 4) to assess for dysfunction in the foundational joints of the pelvis (Greenman 2011).
After a positive finding (indicating dysfunction), the position of the ischial tuberosities on the horizontal plane was used to differentiate between superior innominate (up slip) and pubic symphysis dysfunction. The client had a right-side positive finding in the standing flexion test. Palpation revealed horizontal ischial tuberosities, ruling out innominate up slip. Palpation of the pubic symphysis revealed a right superior pubic symphysis. The symphysis was treated and then retested with a negative result. Next we tested for axial mobility by comparing the lumbar spine in neutral prone to its position in extension and flexion. The rotation of L5 did not change in extension, indicating functional movement. However, in the seated flexion test, L5 rotated right as compared to neutral. This signified that the right facet would not open during flexion, termed right L5 flexion restriction. L5 was then treated (Figure 5) and then retested with a negative
result.
The next section of the algorithm addressed the sacrum (as shown above in Figure 2). The seated flexion test (Figure 6) assessed for the presence of sacroiliac dysfunction (Greenman 2011). As the lumbars flexed, the right posterior, superior iliac spine (PSIS) was quickly dragged up by the spine indicating a right sacroiliac dysfunction. Then with the client prone, palpation revealed the right sacral base anterior and the right inferior-lateral angle of the sacrum posterior, which identified a right anterior nutated sacrum. The sacrum was treated and then retested with a negative result.
Figure 6. Seated flexion test.
After we achieved mobility in the lumbar vertebrae and sacrum, we assessed the movement of the ilia on
the sacrum. The Stork test (one-legged standing test, Figure 7) was used and indicated a right iliosacral
dysfunction (Greenman 2001). I compared the levels of the client’s ASISs and PSISs and found that
she exhibited a right anterior innominate rotation.
I observed that my client’s right innominate was stuck in the push-off part of the gait. The iliosacral joint was treated (Figure 8) and then retested with a negative result.
Post-Algorithm Standing Assessment
The algorithm was completed in twenty minutes. As displayed in the after-algorithm photograph (Figure
9), many compensations were resolved creating a foundation for the rest of the SI session. The client
stood with knees unlocked and pelvis closer to horizontal. There was a decrease in rhomboid tone and thoracic curve had returned. The shoulders were less pulled back. The head was nearly over the shoulders with a marked decrease in jaw tension.
Post-Algorithm Gait Analysis
A video clip of the client’s gait after application of the algorithm can be viewed at http://tinyurl.com/ l4rfz89. Contralateral movement was restored and weight-bearing became more even, as did rotation of
the legs. The right quadratus lumborum released to restore normal swing in the hip.
The Rest of the Session
After application of the algorithm, there were 40 minutes left in the one-hour session. As many of the
compensation patterns were resolved, stabilizing and integrating her structure could progress. My goals
were to increase support in her feet and legs, equalize movement in the pelvis, decompress the lumbars,
and bring those changes up through the head.
1. Support in Feet and Legs
To assess the client’s ankle movement, I passively dorsiflexed the ankles to ninety degrees with the client in a supine position. This mimics the position of the ankle in a standing position with the forces of gravity removed. Dorsiflexing the ankle should have no effect on the rest of the leg. While this was the case in the left leg, this motion caused the right leg to medially rotate.
Looking at the ankle anatomically, the posterior aspect of the talus is narrower than the anterior aspect. Therefore, in dorsiflexion, the malleoli must separate so that anterior talus can fit freely between them. If the malleoli can’t separate, as was the case foundation for the rest of the SI session. The client stood with knees unlocked and pelvis closer to horizontal. There was a decrease in rhomboid tone and thoracic curve had returned. The shoulders were less pulled back. The head was nearly over the shoulders with a marked decrease in jaw tension.
Post-Algorithm Gait Analysis
A video clip of the client’s gait after application of the algorithm can be viewed at http://tinyurl.com/
l4rfz89. Contralateral movement was restored and weight-bearing became more even, as did rotation of
the legs. The right quadratus lumborum released to restore normal swing in the hip.
The Rest of the Session
After application of the algorithm, there were 40 minutes left in the one-hour session. As many of the
compensation patterns were resolved, stabilizing and integrating her structure could progress. My goals
were to increase support in her feet and legs, equalize movement in the pelvis, decompress the lumbars,
and bring those changes up through the head.
1. Support in Feet and Legs
To assess the client’s ankle movement, I passively dorsiflexed the ankles to ninety degrees with the
client in a supine position. This mimics the position of the ankle in a standing position with the forces of
gravity removed. Dorsiflexing the ankle should have no effect on the rest of the leg. While this was the
case in the left leg, this motion caused the right leg to medially rotate.
Looking at the ankle anatomically, the posterior aspect of the talus is narrower than the anterior aspect. Therefore, in dorsiflexion, the malleoli must separate so that anterior talus can fit freely between them. If the malleoli can’t separate, as was the case with the client’s right ankle, a medial rotation occurs
as the talus attempts to navigate the narrow channel.
In standing, this produces a torsion pattern, which moves up the leg into the trunk and causes strain on
the back as well as the knee.
To resolve this problem, I first opened the retinaculum. Then I slowly worked into the interosseous membrane to decompress the tibia and fibula. The result was a smooth flexion of the ankle without a subsequent rotation.
2. Equalize Movement in the Pelvis and Decompress the Lumbars
With the client in a side-lying position, I lengthened the tissues of the lateral line of her waist and pelvis,
similar to third hour work. The client’s fourth hour [medial] line of her right leg was short, while the left
was normal. I equalized the fourth hour lines and integrated them with slight work in the floor of her
mouth.
3. Translate Changes up Through the Head
With the client supine, I mobilized the restricted cervical facets, which always accompany lumbar and
sacral restrictions. I also released the fascia of the cervical erectors and scalenes.
4. Finishing Benchwork and Tracking
The client sat on the bench and I placed a light block between her knees. I instructed her to feel her feet
on the ground and curl over. I applied an anterior medial pressure to her low back, with my fist. The
client was instructed to meet my pressure by pushing from her feet, connecting her low back to the ground, through her inner line.
Next, with the client standing in front of me, I applied pressure into her ankles with my great (first) toes. Holding just below her knees and tracking them forward, she was instructed to bend and straighten her knees.
After Session Standing Assessment
As our session ended, the client had settled around her line. The weight of her body was over her legs and feet, and the pelvis closer to horizontal. There was an ease in her back, diaphragm, and shoulders.
The client stated that she felt a sense of integration
and groundedness.
Client Education
Knowledge gives a person power by decreasing anxiety and increasing body awareness. I educate my
clients by explaining how each restriction contributes to pain. In this particular case, we discussed the
importance of a stable, yet mobile, pubic symphysis.
Although the client did not feel pain in the front of her body, dysfunction at the symphysis was most likely the beginning of her problem. It changed the length of one leg and altered the range of motion of the same-side sacroiliac joint causing a domino effect through the rest of the pelvis and low back.
Aside from pregnancy and delivery, in my experience, the most common cause of a right superior pubic symphysis is stepping off of a curb and landing on a straight leg. The resulting jolt up the leg stimulates the neuromuscular reflex to lock the joint. More likely for this client: Aggressive yoga practices can also be the cause. Attempts to stretch the adductors can lead to stretching the ligaments of the symphysis. It is important to strengthen the secondary stabilizers of the symphysis: the transversus abdominis and anterior pelvic floor.
I would refer most clients with this dysfunction to a Pilates instructor. Considering this client’s yoga background, I recommended the mula and uddiyanna bandas.
Some of the indications for using this algorithm are alteration in gait, leg length discrepancy, or discomfort in the area of the low back, pelvis, legs, or feet.
Conclusion
The use of algorithms is in no way intended to replace the invaluable process of seeing. This case study does, however, demonstrate that the use of an algorithm and joint mobilization can greatly enhance and expedite the process of integration. The use of algorithms is useful not only in a post-ten session, but also throughout the series. Some of the indications for using this algorithm are alteration in gait, leg length discrepancy, or discomfort in the area of the low back, pelvis, legs, or feet. This metaphor summarizes my view of the usefulness of the joint restriction algorithms: As structural integrators, fascia is where we dance. If there is glass on the dance floor, doesn’t it makes sense to first sweep the floor?
References
deMahy, J. (2013). Joint restriction in structural integration, (Vol. 1, 4th Ed.). Self published.
Greenman, P. (2011). Principles of manual medicine, (4th Ed.). Lippincott Williams & Wilkins.
Iyengar, M. S. (2009). The Medical Algorithm Project. Retrieved from http://arxiv.org/ftp/arxiv/ papers/0908/0908.0932.pdf
Mitchell, F. L. (1995), The muscle energy manual: Concepts and mechanisms, the musculoskeletal screen, cervical region evaluation and treatment. MET Press.