So, today we're going to be talking about osteopathic structural exams and treatments or chief complaints of abdominal and pelvic pain. We're going to be reviewing the five treatment models of osteopathic manipulation as a way to approach patients, instead of memorizing algorithms or memorizing a specific set of techniques. We'll talk about how we should be thinking about... ...patients and what systems we should be trying to address. We'll, demonstrate the relevance of somatic functions from the various body regions, as they relate to abdominal and pelvic pain, and we'll review the components for diagnosing. Somatic dysfunction of the abdomen and pelvis, including fascial, strains pubic shear diagnosis, as well as relevant muscle hypertonicity. We'll also give a sample of osteopathic treatment... ...techniques that might be used for abdominal and pelvic pain. So, often when I asked the question to students at, what are the five models of osteopathic. treatment? They often rattle off types of techniques, muscle energy, your leg kind of strain, and, yes, those are types of techniques. But all of those types of techniques might be... ...applied to each of these models of osteopathic manipulation. And the five models of by mechanical model, which I think is what most people think about when they think about osteopathic manipulation. They think about the biomechanical, model will talk about the neurological model and we'll narrow that down a little bit, the respiratory... ...circulatory model and there's also the metabolic... ...energy model and the behavioral model, we're going to focus on these first three and I'm going to narrow them down just a little bit... ...more specifically talk about the autonomics when we're talking about the neurological model and talk about lymphatics for the respiratory circulatory model. So, starting with the neurologic model. As we know, there's two components, there's a parasympathetic and sympathetic, innervations of our systems, autonomic nervous system. Most of the parasympathetic. Innervation of the body comes from the vagus nerve but that goes down only to the transverse colon. From there we pick up the pelvic, splanchnic arise... ...from S2 S3 and S4 of the sacral plexus. parasympathetic activity and those deception of the bladder descending colon sigmoid colon and... ...rectum come from these pelvic, splanchnics may increase peristalsis and contraction of the... ...bladder and the rectum for urination and defecation, respectively. They also stimulate genital erectile tissues. When we talk about pelvic splanchnic or sacral... ...plexus and we want to talk about some axis functions that may contribute to them. from a bony standpoint. You think about sacral torsions. Any SI joint dysfunctions as well as innominate... ...dysfunctions and we'll soft tissue standpoint. We can talk about fascial restrictions as well... ...as muscular restrictions specifically of the piriformis and pelvic floor, which we'll talk about more in a moment. For a sympathetic standpoint. We think of the lower sympathetic chain ganglion... ...which runs into really to the rib heads. That's it internally to the transverse processes of the thoracic spine but in terms of innovation of the GU system we really think of T10 to L2. And this causes bladder contraction as well as... ...allowing for increased capacity without increasing truce arresting pressure. It also increases internal urinary sphincter tone. additionally, it increases vascular dilatation, as well as vaginal secretions and is responsible for vaginal contractions and contractions of the pelvic floor muscles that are associated with orgasms. So, when we think of somatic dysfunctions that... ...could be causing sympathetic either irritation and therefore increase sympathetic innervations, or obstruction and therefore, decreasing sympathetic innervations. We think of tender points as well as tissue texture changes over the transverse processes of the thoracic Vertebra specifically erector spinae muscles as well as ribbed as functions, specifically posterior components of those functions and rotated vertebra. Moving on to the biomechanical model. we are reminded that tensegrity concept that... ...says that we are allowed to ambulate and move through the world because of the balance of tensions of structures, not just bony because you can't stack the bones of the skeletal systems and have them even be erect that alone mobilized. It really is the balance of tensions of muscles ligaments, tendons, and fascia that allow us to move and ambulate as they attached and balanced. Forces across our skeletal system. So with that in mind, we're going to talk about not just throwing structures but also ligaments and musculature as well. And here we are reminded of a couple of components. We were just talking about the pelvic splanchnic and, how they exit from the sacrum, as, to S3 and S4 But here we see the anterior, sacroiliac ligaments and its connection in processing of the sacroiliac joint. And we also see the iliolumbar ligament, and this is kind of interesting and so much as we talked about t, 10 to L2 affecting sympathetics, but to the degree that the lumbars attachments to the lumbar, ligament affect the innominate, and can Cascade into the SI joint more indirectly, the lower lumbar scan. Now affect the A sympathetic Innovations as well. We're also reminded of the pubic symphysis and the interview with disc and of course, the surrounding... ...ligamentous components of the vertebra themselves and into the lower extremity. Moving on to the muscular components, we have to think of muscles when we think of abdominal pain, it's an abdominal cavity that is surrounded circumferentially by abdominal musculature posteriorly, you have the lumbar vertebra but also the lumbar musculature. inferiorly. You have the pelvic floor and the the innominate themselves. and then the forces that take place from the lower extremity as well. So we think about muscles of the lumbar spine, the The sacrum but also of the lower extremities... ...and so I highlight quadratus lumborum that... ...attaches to the lumbar spine as well as to the 12th rib and the posterior one-third of the iliac crest of the innominate. We think about the iliopsoas muscles which attaches to the lumbar spine as well. And joins with iliacus and inserts on the lesser trochanter of the femur, the crosses into the. pelvic bowl that could contribute or be Used by... ...patients as pelvic pain and then we are reminded of the attachments and we'll talk a little bit more later about the adductor muscles and their... ...attachment to the pubic ring and the forces at those can insert. But how those may be perceived by patients as inguinal or lower pelvic pain? And we look for hypertonicity of tender points as well as fascial restrictions in these muscles. A little ambitious with this picture. We see our ad after muscles here. We see our little so as I'll show you a picture of remind you of piriformis and hip extensors but also quadriceps muscles as they attached to the dominance as well, and posteriorly the hamstrings into the pubic rim as well. When we consider some act as functions of the anonymous themselves, we think of all the innominate dysfunctions that can take place and those can includes anterior and posterior. Nominate dysfunction is in flare and outs, layer of how they nominate move, as well as Superior and inferior shears or the innominate. We also consider rotations at just the pubic symphysis, which we'll talk a bit about more about in a moment and how those can be perceived as vaginal pains or lower pelvic pain. We're reminded that the pubic symphysis is held... ...together by the dense cartilage of the interpubic disc. and that normally they should be less than 1 centimeter apart. These two components of the pubic symphysis. that with stress, that can expand dramatically in the second and third trimester of pregnancy. and can in normal, physiologic motion have 12... ...degrees rotation to allow for gate? Here, we're looking at an x-ray AP View and we... ...see a normal alignment of the pubic symphysis, the pubic rim, Who is think about pubic diagnosis from a osteopathic... ...standpoint we can either have a ducted or compressed... ...pubic bones and that can be perceived as pain again at the pubic symphysis and have a positive... ...standing selection test but you have restriction of motion as you try to ab duct the pelvis, as you externally rotate the AB duct the upper... ...portions of lower extremity or femur you would find restrictions there. For gaps pubic symphysis which we see in childbirth. You also have a positive standing flexion test. You also have pain at the pubic symphysis, but we have restriction of motion in adduction with a gap pubic symphysis. And here we see an APB with a gap pubic symphysis at one point seven centimeters of separation. As you mentioned before, you can have Shears of the pubic symphysis. And so, this is really speaking. Not that the entire innominate is shifted, but just at the anterior portion is rotated. Such that we have a separation from that cartilaginous disc that should keep it in place. or shearing through that disk. And again, we see a positive standing flexion test and we see a pubic ramus That is higher on the side of restriction. from a structural exam standpoint, it looks like a posterior and dominant except that you see a cute tendinous epic symphysis. Conversely, you have an inferior pubic sheer again. You have a sign of positive selection test at that side, or positive ASIS compression test. And you see the pubic ramus is lower. It looks like an anterior and dominant when you look at landmarks as well. And here we see a sheer. so we see posteriorly SI joint is intact, and the iliac crests are level. But here anteriorly at the pubic symphysis, we see a shift in that speaks to a shear. And whether we would say that this is a superior Shear or an inferior Shear, would you be based on whether that standing flexion test for that ASIS compression Test was positive on the patient's, right or on the patient's left As we look to address an innominate dysfunctions, as well as specifically pubic symphysis is functions. We look to the adductor muscles. to mobilize and put tension on this anterior rim of the pubic bones. and we're reminded of adductor brevis, longus, and magnus. So, when patients come into me. with pubic pain or lower pelvic pain, I always... ...palpate through the adductor musculature To look for tenderness or hypertonicity or fascial restrictions, that could impede the mobilization or have mobilized and displaced, the pubic bones and its functionality. Conversely, we can look at the abductor muscles, which is primarily for hip abduction, has primarily gluteus medius, minimus and tensor Fascia Lata, we also have some motion here at Sartorius and piriformis. And last but not least we are reminded from a muscular standpoint to look at iliopsoas as I mentioned before. Tenderness to restriction through this area can be perceived as growing pain or lower abdominal pain. and piriformis restrictions as it applies and puts tension on the sacrum. We're reminded that the piriformis attaches to the anterior portion of the sacrum and can therefore, cause and contribute to sacral torsion We can not only affect the autonomics the parasympathetic. At the sacral plexus. But biomechanically put stress on the posterior aspect of the pelvic Bowl, as well as cause SI joint dysfunction, as well. Last but not least, we move on to the respiratory... ...circulatory model and we are primarily going to talk about this from a lymphatic standpoint. We're reminded that the abdominal cavity again is surrounded by abdominal musculature circumferentially... ...superiorly by the respiratory diaphragm and... ...inferiorly by the pelvic floor muscles. Not only can these have fascial restrictions and... ...muscular restrictions that can contribute and be perceived as pain but they can also cause congestion from specifically lymphatic standpoint but also as it relates to blood flow and innervation to those areas. Looking at the respiratory diaphragm or reminded that attaches to the lower ribs six through 10 specifically. and posteriorly also attaches to the 11th and 12th rib through the crura. We have here, centrally the central tendon and a moment. I'll remind everyone that the thoracic duct passes through the respiratory diaphragm, next to the aorta. And again from a lymphatic standpoint, the respiratory... ...diaphragm is a major lymphatic pump for the... ...body reminded that the lymphatic system doesn't have musculature of its own and relies on muscular contraction. for movement and the respiratory diaphragm helps with lymphatic throw through the abdominal and thoracic cavity through pressure gradients. And so we see these attachments not just the lower ribs, but to the lower thoracic and upper lumbar spine as well as their effect on the posterior ribs. And here we see that diagram that I mentioned before here, just below the diaphragm and passing through the... ...aortic Hiatus with the aorta turning into the... ...thoracic duct before it rises superiorly to the superior mediastinum. Inferiorly. We look at the pelvic floor made of the levator ani and coccygeus, as well, not shown here, I'll show in a moment. and those attachments to the posterior aspect of the pubic ramus. We also have optimatus internist and if we go more posteriorly, we can see piriformis here and coccygeuse here, all of which creating the pelvic floor. If we look from this is a superior, inferior view. If we look from an anterior Superior view, we see the Deep transverse perineal muscle, but we also see our ischial tuberosity or our sits muscle, which becomes a landmark for knowing where you're located, as you try and find these pelvic floor muscles. So, we have the ischial tuberosity, as well as the coccyx to give us a sense of where we are in this region as we're palpating and doing direct inhibition, or fascial release. Here, we're looking at the lateral View and again, just to appreciate the posterior aspects of the... ...piriformis on to the sacrum coccidiosis, and the rest will be the Deep transverse peroneal muscles. Forming the pelvic floor. This is a transverse View. And again, you'd be... ...coming through the Deep transverse perineal muscle, before we get to the Deep levator and I and having to apply forces, more laterally to have any effect on obturator intemus. So again, as we look at the respiratory diaphragm and pelvic floor and the. circumferential muscles of the abdomen, you see that with we can abdominal musculature. It changes the tension that we have on the lumbar spine, which of course would affect not only the ribs, but also the respiratory diaphragm and the shifting and rotation of the pelvis, which would affect the pelvic floor. In this diagram, we're getting a more broad view of the lymphatic system and again, reminded here we have the cisterna chyli that would sit just below the respiratory... ...diaphragm and pass through the aortic hiatus as it rises up as a thoracic duct into the thoracic a thoracic cavity. Inferiorly we see our lumbar trunk and Lumbar, lymph nodes. But we are also reminded of The inguinal both deep and superficial inguinal lymph nodes that happen here in the groin, as well as in the upper thigh. Continuing our conversation about circulation, we consider fascial restrictions that can significantly affect both, the GI and the GU system. and have inhibition of motion of the lymphatic system as it passes through the abdominal cavity. So let us consider a patient. We have a 45 year old female who presents the office complaining of lower abdominal pain, that occurs monthly with her period, which is regular occurring, every 28 days. Her last monthly period is today or started today and she denies radiation into her legs. Any weakness or incontinence of bowel or bladder. Review of systems - Is additionally, positive for bloating, nausea, loose stools as well as lower abdominal cramping, but she denies dysuria, polyuria or hamaturia. She does complain of muscle spasms and pain in her lower back, but also denies any vomiting or constipation. In her history, she's up to date on her pap smears and all of her. Do you test and she has no STD history. And all normal pap smears. She does have a history of dysmenorrhea but is otherwise - in her history. On physical exam, she's 5' 6", 140 pounds. With a normal BMI, she has normal vitals. And the only thing positive is really her abdominal... ...exam which is although soft, She's mildly distended. If she has hyperactive bowel sounds and Mild tenderness of her lower abdomen abdomen, diffusely with no rebound and no guarding. From a biomechanical standpoint either. I 6 or T 10 to T 12 or neutral, rotate it right segment... ...left L 3-5 or rotate it right side bent left. She's a left quadratus lumborum spasm. She has a pre sequel fascial restrictions with these emotion inferiorly left and clockwise. She's a right on left Sacral Torsion a left anterior innominate. with regards to her lower extremities, she has a tender point of her left. So as and restriction of motion on the Thomas Test and she's a right piriformis muscle hypertrophy necessity. So, when we are looking at. Coming up with a treatment plan, we really have to define realistic goals. And again, we've already narrowed down the treatment models that were looking at, which is the neurologic respiratory circulatory and biomechanical models. Looking at those three components, we want to think about what are the components that were... ...looking at and how can we address those. So. we can look at her thoracic and lumbar spine to... ...address the sympathetics as well as looking for Fascial restrictions of the abdomen and restrictions of motion, and the pelvic diaphragm and respiratory diaphragm. And then we can identify one, two, three techniques for body region that we can treat to address those three systems. So as we look at those three systems, we have an overlap, there's 10 body regions, that's how we divide the body from a somatic dysfunction standpoint and we have overlap, in terms of their contributions, we can look at the thoracis for, sympathetic innervations, as well as the upper lumbars as well. We can look at the pelvis and safe from for parasympathetic innervation. So treating dysfunctions of these body regions can help with the autonomic innovations that maybe... ...Contributing to pain for this visceral component from a respiratory circulatory component. We look at the abdomen, specifically the respiratory diaphragm. And we can also look at look for lymphatic congestion through the abdomen as well. More broadly, we can also, look at the pelvic floor, namasthe and safe moments. Those are contributing to the pelvic floor as well. And lastly, of course biomechanically, you can look for fascial frictions in the abdomen and hypertonicity. muscles in the lumbar and lower extremities. So thinking about techniques that we can apply to these body regions, we can do muscle energy to the thoracic region but really, any treatments for those dysfunction, as we could fell a counter strain, soft tissue techniques. Anything. can be used as long as the patient can tolerate it. Good do BLT to the spine as well. I really enjoy these techniques and we're talking about them later. And really, what you do is you spring anteriorly on the spinous... ...processes and where you don't find spraying or where you find tenderness, you can then apply an anterior force and lift. And rotate the vertebrae through the spinous processes to balance tension across the ligaments of the spine. This is really great for fine tuning. So once we get to those big treatments of soft tissue muscle energy hqla, BLT is great for fine tuning restrictions that can really hold up the system. Big fan of counterstrain, and I don't think it's used nearly enough. I think because it's time-consuming or is perceived as time consuming, but you can certainly do counter, strain or BLT in this patients, case. to the lumbar spine and just the quadratus lumborum. As well as treating the tender point that she presented with with counter strain, We can treat our sacral and innominate dysfunctions with muscle energy. I'm also a huge fan of articulatory techniques, but whatever my osteopathic Position is just like there are dozens of statins and ACE inhibitors. Everyone has their first choice and their second... ...choice for those. classes of medications in medical school, you... ...probably learned a half a dozen to a dozen techniques for every body region. You have to decide what your favorite technique is or approaches, and how a backup have one or two types of techniques for each of the body, we can set for treating and use those and know your patient population. For the abdominal region. We can talk about that treating with myofascial... ...release which is often really well tolerated and very helpful especially for when there's bloating involved. or when it's cramping involved. That's often very helpful for patients and of course, doing myofascial release to the pre sacral regions into the pelvic floor during direct inhibition through the musculature, So in summary, when we're talking about osteopathic manipulative treatment plans. Think about your five treatment models. And then think about specifically biomechanic, autonomic and respiratory, circulatory components as it relates to pelvic and abdominal pain. As these can often contribute to the pain that's being presented. Thank you. So, this is the lab demonstration that... ...correlates with the lecture on osteopathic. Structural examine treatment for abdominal and pelvic pain. We're going to be reviewing the case that we introduced in the lecture and talking about how to do a focused exam and treatment. So to revisit we had a 45 year old female patient with a history of dysmenorrhea who presented to the office complaining of lower abdominal pain. That occurs monthly with her period, which is regular, and occurs every 28 days. Her last menstrual period started today. She denies any radiation of her pain into her leg. She denies any weakness or any incontinence of bowel or bladder. To review her biomechanical exam, she had T10 to T12 neutral, rotated RRSL. And this also correlates with a sympathetic Integrations. To the GU system she had L3-L5 RRSL, but left with a left corner to some boring spasm. Both of these functions can affect the sacrum at L5 and the posterior portion of the innominate, because of the ligamentous attachments and the... ...connection of a L5 to the sacrum. To increase sacral fascial restrictions with ease of motion left and clockwise this dysfunction can infect her lymphatics, as well as biomechanically. Cause pain should a right on left signal torsion, which can be correlated with her parasympathetic, innervation to the GU system left anterior nominate, which can biomechanically cause pain as well as affecting her parasympathetic innervation to GU system. And she's left psoas tender point and right piriformis muscle have density. These can respectively caused biomechanical pain as well as affecting the parasympathetic innervation to the GU system. as we mentioned and reviewed in the lecture, there are five models of osteopathic treatment. We're going to focus on three specifically the autonomics under the neurological model. The respiratory circulatory model and the biomechanical model. To review We're going to do muscle energy for her thoracic and lumbar spine, will actually talk about BLT to the thoracic spine as well. We'll review presacral fascial myofascial release do articulatory, technique for her right on left sacral torsion. Will do muscle energy for her left Anterior dominant and I'll also review pelvic floor, release as direct inhibition. Lastly, we'll do counter stream for her left psoas tenderpoint and muscle energy for her, right piriformis dysfunction. And with that, we're going to start with our demonstration. So here we have our patient and just to review our landmarks, we're going to start with looking at her spinous... ...processes and that's going to be our landmarks. So, in this patient, I would find that inferior angle of her scapula which would put me at t7 and finding the spine of the scapula. I would count down to the T8, T9, T10. She was T10, T11, T12 or rotated right and side bent left. So I'm going to put the heel of my hand on that right... And then I'm going to ask the patient to grab her elbows. and I'm going to come up and underneath, I'm going to side bendt her, right? And rotate her left to take her to her barrier. We're going to do the same technique from the other direction. So we swing your legs around, basically. So doing the same thing here, I'm going to have her, grab her elbow. I'm going to find those same landmarks and put the heel of my hand over. That right, rotated side, I'm going to come up and under, and if it's too far to reach, I can grab here at her home forearms. I'm going to side bend to her right. Which one matches her barrier and would take her to the left which no barrier and ask for to gently turn her body back to the left, Turn back. The right, one, two, three, four, five - relax. And I'll side bend with her a little bit more. I would say a little bit more and have her turn again. And stop. And side bend and rotate a little bit more and try again. And stop to do. The lumbar spine will just have her Flex forward to get down lower into the portion of the lumbar... ...spine and our setup would be the same. Next we have the time and put your back to the camera. Again, we're going to talk about BLT to respond and balanced ligamentous tension. Not the delicious bacon, lettuce and tomato. Balance of the tension, is really looking at How can we treat the core of the spine through the ligaments. And this is a technique that I use a lot on a variety of patients. But anyone that's coming in with anything that... ...affects the vertebra of the thoracic and lumbar spine in particular? So again, we're going to use our spinous processes as our... ...landmark and I'm just showing you my hands on so that one of the patients down, you'll understand that where my fingers are, I'm coming up underneath. The patient on finding the spinous processes. With each of my fingers, I'm springing anteriorly. into the spinous processes. I'm looking for spring, I have you lay on your back room, please. Just a little bit. Thank you. So now my hands are up underneath her thoracic... ...spine and I'm simply lifting my fingers anteriorly as I spring along, the spinous processes where there's spring, there's no dysfunction. If I feel that this resistance or push back or if you like a peg, all of those would note dysfunction, you'll roll with me again... ... and roll back and I can lift anteriorly and just hold now. If I want to have more nuance to the motion of the vertebra, I can pull the spinous process towards me and should rotate the vertebra way. Or I can push it away from me, what should rotate... ...the vertebral body towards me and find that balance point. So, that it is, this is my vertebra and here's a vertebral body and this is - process and these are the transfer process. If I'm up underneath the patient and I'm lifting anteriorly towards the ceiling. If I pull the spinous process towards Me the vertebral... ...body will take to wait for me if I push it away from me, it rotates the vertebral body towards me. And this is a great technique to use when you're trying to fine-tune restrictions in the thoracic spine, affecting the ligaments as well as a small rotatory... ...muscles that only 2 verse 1 or 2 joint spaces. This is especially useful actually in helping to treat the entire ribcage because as we know we have an overlap of the rib of the neck of the rib and the transverse processes of the vertebra. So if again, if this is our vertebra is that transverse process, normally will see that overlap of the rib to the transverse process. So that wherever the vertebra goes so goes through. So in treating her, I can wait for that release and then we motion... ...check to see if I have increased motion, increased spring in those thoracic vertebra. Next, we're going to treat her innominate dysfunction. So she had a left anterior, innominate dysfunction, which means from looking at her pelvis, this left side was rotated forward. So we have back into her barrier and have her contract, her gluteal muscles and her hamstring muscles in order to help mobilize that innominate, I'm entering the knee. and she was fairly small. I can rest it on my forearm for larger patients, I can put it on my shoulder and flex her hip up. And have her gently push towards her feet. One, two, three, four, five, relaxed. And each time taking her to her barrier, having her push again. And relax, and push it down. When we do that three to five times and final stretch. I don't bring her back down. Whatever you're trying to diagnose. The innominate, our landmark of choice, is going to be the ASIS. In larger patients, sometimes Physicians and students will tell me they can't find the ASIS because of the size of the patient. But I always remind people is that no one carries adipose over there ASIS. So if you start at the top of the thighs, with the heels of your hands and work your way up that you'll hit the ASIS and then you can check levels, sometimes you might have a panis that's why over. The ASIS you might have to lift the pan in order to get to them. But again, no, one carries actual adipose tissues on their ASIS. The ASIS is also going to be our Landmark for our constraint tender point for the psoas muscle. So again onto the heels of my hands and come up to find that Asis and from medial to the Asis and I'll ask is that tender there. So we're going to call which turn this you have there 100%; And with my thumb and my finger. Never moving from that spot. I'm going to flex her hip and her knee. I'm going to externally rotate and an AB duct her leg. And now, again, I'm going to hold it. In this position, if I found her life to be too heavy, I can sit down next to her and rest it on my shoulder to have her in this position. So, now in this position, how must have yours? Do you have. So, we're going for at least 70 percent reduction so. so you have zero. Fantastic. So, here we are. Holding our position would hold this for 90 seconds. And then, we're going to bring her back down to neutral, and we assess how much turn is do. You have there now? Non fantastic? So, that would be our psoas, and that's important. Psoas a big muscle to pay attention to, when you're talking about abdominal pain, but specifically pelvic pain because it's really iliopsoas, right? Illiacis is attaching to the anterior fossa of the innominate and joining with. psoas can often present with pain when it's tight in that area and so counter strain BLT other techniques that area to treat. Those muscles can help with what is perceived as probably paying by our patients. Next, we're going to do piriformis muscle energy. If we work all the piriformis attaches to the... ...anterior surface of the sacrum and inserts onto the greater trochanter. And this is important too. Again, because of its effects on the sacrum itself. So what we can do is a couple of things. So in testing, we can do the fair's test, which is flexion, ab duction, internal rotation. And if that elicited pain or had a restriction of motion, it would say that that was positive for type performance. And in treatment, I can bring her leg across and cross your leg over. and bring her knee medially. To bring that piriformis to the barrier. It's an external rotators or bring it into internal rotation, really helps and then gently, I'm going to have a push out into me. One, two, three, four, five, relax, push a little further. Shout 12345, relax and push down. One, two, three, four, five, five, stretch. And I can come back and I can reassess the fair test to see how well she moves. Additionally, because she had the sacral torsion we can treat with articulatory as we're treated the articulatory or we're going to Gap The SI joint and then add a circumferential motion. So if this is her sacrum and this is her Flex leg, I'm going to take her knee and bring it medially, which is going to bring the innominate, posteriorly more laterally, and then I'm going to apply a posterior lateral course, you have a shearing motion to bring innominate... ...away from the stay from...to Gap that SI. And then I'm going to rotate the leg to help with... ...stretching and doing articulatory motion through that SI joint. So here, I'm going to flex her knee. I'm going to bring her medially if I really want to add Force, I can reach across the table and pull down to the table for my shoulder into that, but I can press my body weight. And now I can bring her into a circular motion or that SI joint dysfunction and most patients really tolerate, this very well. They really like it. It's pretty effective. Next, we're going to do a pelvic floor, release. I'm going to show it to you in the prone position, only because it's easier to see what I'm doing. But I tend to do this treatment in the Supine... ...position and I'll show that as well when you turn over onto your belly. So when we're doing pelvic floor, release, we look for the ischial tuberosities as our landmarks, and we're going to come medial to those Ischial ...Tuberosity to hit that levator and illiococcygeus muscle. So I'm going to bring my thumb up underneath. I'm going to press superiorly and laterally to help stretch that muscle as direct Vision technique. So again, I'm coming up from underneath the find that musculature and I can do one or both sides at the same time and I'm pushing superiorly and laterally. And avoiding a perception of indiscretion. I'm keeping my the rest of my hands off of the patient and focusing, my course on the thumbs only. I'm going to show you this exact same technique in a Supine position. Can you turn over onto your back? So for this, we have a patient lie on their back, if your hips and knees, Flex with their feet apart, and their knees together, and that helps to bring the Ischial Tuberosity... ...apart to make more room for your palpation. So, with this, I'm going to reach across the patient. Underneath her legs, find her Ischial Tuberosity. And again, my horse is superiorly and lateral. I can also use my fingers on the ipsilateral side again. Finding that Ischial Tuberosity, come medial to that and go superiorly and laterally. I'm what I'm waiting for is to feel released as I'm pressing to the musculature, and I can palpate and really de posteriorly for various points of restriction. And I normally ask the patient if she has the... ...attentiveness but whether or not they have ton of those. I'm not I'm looking for restriction of motion. Lastly, we'll talk about doing a faster release for the abdomen and presacral fascial release. In particular, though the Motions I'm going to do would apply anywhere for this. I'm going to have my hand. My post your hand up underneath her sacral base. And to get there, I'm going to take her knees and lock them away from me, just so I can get my hand into her sacral base. I'm going to leave her hips and knees flexed as that softens The abdominal wall I want to find her ASISs, and I'm going to come meet up to that. I'm going to make a see with my hands and come medial to the Asis. I'm going to apply enough posterior pressure, that I can feel that on my posterior hand. So as I'm pressing, I go, okay, I can feel that force. That's how I know I'm deep enough. As long as the patient can tolerate, the patient can't tolerate that Force. I would just back up my pressure by about a third until I got to a place where they could tolerate it, or I would have to try something else. In this patients case, her... ...motion of ease was inferiorly to her left and clockwise. I can either exaggerated that motion for indirect... ...myofascial release or I can go in the opposite direction to her barrier, which would be to her right Superior and counterclockwise and since I'm a direct kind of, girl, that's the... ...direction we're going with direct myofascial, release. And again, I should be able to feel with my posterior hand, some of that motion that's happening with my anterior hand until I feel release, this is great for lymphatic release. It also helps with biomechanical components of pain, And then once I feel that release, I would come back and we assess left-to-right superiorly, inferiorly, clockwise and counterclockwise. So in summary, as we think about abdominal and pelvic pain, we should really focus on how we want to look at the patient. I recommend looking at the autonomics and this case, if you look talking about the GU system, you'd be looking at the lower thoracic sniper lumbars, looking at the innominate and pelvis, but for biomechanical and parasympathetic innervation as well as the lower extremities. And the abdomen themselves also provide mechanic and lymphatic components. I hope this has helped you as Look at your patients to offer, additional care to them. Thank you. And have a great day.

osteopathic exams

abdominal pain

pelvic pain

treatment models

somatic dysfunction

treatment techniques

autonomic nervous system

patient-centered approach