Ms. A is a 45-year-old female. She is self-employed and has a varied week that is split between studying for a PhD, lecturing and working with clients as a bio-mechanist. She enjoys walking her dog and spends a lot of time working on her nutritional and general health. She first presented being concerned about her back. She reported that it was a ‘daily issue’ at present, and recently, whilst on a course, was told that she had a spondylolisthesis of her L5 vertebra on S1. She was significantly concerned about this and decided to explore treatment options before her condition deteriorated.
Past medical history
In the past Ms. A had been a personal trainer and was incredibly fit and active. She was working out daily and pushing her body to the limit, with high-intensity, weights and endurance training. She also enjoyed martial arts and had had many injuries with this over the years. In 2006 she awoke with paresthesia in both legs and was diagnosed (on MRI) as having prolapsed her L4/L5 and L5/S1 vertebral discs. She was referred to a rheumatologist (the reason for this is unclear, but is apparently the norm for where she lives) and medicated. She also received acupuncture for her pain and over time the pain reduced. She has had some form of low back pain (LBP) ever since and has had a long history of analgesic medication plus various therapies.
Other relevant medical history includes: Chronic Fatigue Syndrome (CFS); Fibromyalgia; Post-Traumatic Stress Disorder (PTSD); Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE); Left shoulder adhesive capsulitis; shortened ulna on the right possibly from an injury during martial arts (she is unsure); bony spurs in her left ankle; multiple whiplash injuries and concussions.
Over the past three months she has been working with a company specializing in orthodontic work to see if orthodontic procedures improve her pain and function. She had already agreed to work with them as a case study. She has now had braces fitted on her teeth and wears a mouth guard day and night. She reports that she had poor alignment of her canines, and that the braces were fitted to improve this. I believe that use of the mouth guard is to try and reduce tension in her temporo-mandibular joint. We discussed that the concurrent dental treatment may make it difficult to fully assess our progress or identify the need to alter our treatment. She was unable to opt-out of the orthodontic treatment and wanted to persist with her physiotherapy, so we agreed to note it as an external ‘correction’ with which we cannot presently interfere.
Ms. A’s meaningful complaint is right-sided low lumbar back pain and a fear of spondylolisthesis. Her meaningful task is to be able to run again without low back pain and with confidence that she is not making any of her back pathology any worse.
Her cognitive beliefs are that she has an old physical injury to her back which affected her vertebral discs in her lumbar spine. She is very concerned about having a spondylolisthesis and making her back worse. She feels de-conditioned in general and unable to exercise in the way that she would like. Her belief is that there is a physical reason for her pain. She is open to the fact that her past life-trauma may be a contributing factor.
Standing postural screen
The reason for choosing the standing screen is to establish the starting point of Ms. A’s body; how she organises herself in an upright position. Multiple torsions are likely to be felt in most people’s bodies, and they may change frequently, however having a baseline enables the therapist to determine likely sites of sub-optimal performance that can then be tested further within the screening tests. It is useful to start with a standing screen before looking at specific tests for running as any sites that demonstrate sub-optimal alignment, biomechanics and/or control are likely to be relevant and be used to determine the overall ‘driver’. It will also give an idea of any habitual posture.
Standing screen results
Her pelvis was rotated to the left in the transverse plane (TPR (L)) and she also had an intra-pelvic torsion (IPT (L)) to the left which means that the right innominate was anteriorly rotated, left innominate posteriorly rotated. The sacrum was rotated to the left and nutated. A rotation of the pelvis is a physiological movement; however, it is non-optimal for quiet standing and is therefore charted as non-optimal.
Her right head of femur was anterior within the acetabulum compared with the left. It is possible that the right hip is therefore causing the pelvis to rotate to the left, but we cannot determine this without further testing, so again, although physiological we note the finding as non-optimal.
On palpation of the lumbar spine all vertebrae were rotated to the left which in standing is congruent with the pelvis and right hip for left rotation, but non-optimal for quiet standing.
Multiple upper thoracic ring shifts were found on either side, in the mid-axillary line.
- TR (thoracic ring) 3 – translated to the right and rotated to the left (congruent with pelvis/hip/lumbar spine)
- TR4- translated to the left and rotated to the right (incongruent with TR3, pelvis, hip, lumbar spine)
- TR5- translated to the right and rotated to the left (congruent with TR3, lumbar spine, pelvis, hip
Her right eye was deeper than the left eye (which suggests that her sphenoid bone is rotated to the right). The right temporal bone was anteriorly rotated and the left temporal bone posteriorly rotated which suggests an ICT (intra-cranial torsion) to the left with an incongruent sphenoid.
Her mandible was deviated to the right. On palpation her temporal bones felt as though they were ‘walking’. It is agreed between cranial therapists that the bones of the cranium should move rhythmically and symmetrically adducting and abducting, any asymmetrical movement is again noted as non-optimal.
Her right clavicle was anteriorly rotated and left clavicle was posteriorly rotated (causing a torsion to the left) which is congruent with her pelvis, right hip and lumbar spine. Her right humerus was sitting anteriorly in the glenoid more than that of the left side. Using Shirley Sahrmann’s one third: two third theory for the shoulder it was therefore deemed as non-optimal. Her temporal bones (ICT) are congruent with her clavicles for the task of standing. Her sphenoid, C5 and TR4 are incongruent.
Information added after Diane’s question below: The best over-all correction for standing was TRs 3 and 4.
One leg stand (OLS)
On testing for control of the sacroiliac Joints (SIJs) in standing they were found to lose control bilaterally. This is determined by placing one hand on the spine of the sacrum and the other hand on one innominate, holding as much of the bone as possible to maximise the potential for feeling motion away from the axis of movement. As the patient starts to move, the therapist monitors for any movement between the bones. A ‘stable’ or well controlled joint would not have any relative motion between the sacrum and the innominate. Loss of control can occur at the initiation of movement, or late into the task. The timing is useful to note as it can help to determine which area of the body fails first. It was noted that both SIJs ‘unlock’ or move early in the task.
All the areas noted in the standing screen remained shifted. The best correction for this task was noted as the upper thoracic rings (3 and 4). TR4 is the ring not congruent with the pelvis, hip and lumbar spine. As TR 4 was corrected, 3 started to shift more on the opposite side. The rings were therefore ‘glued’ meaning that a vector needed to be released between them enabling TR4 to be fully corrected. The combination of correcting both TR3 and TR4 together improved the other sites over-all and the task felt easy, light and connected for the patient. I was not able to fully correct the 4th thoracic ring, but its correction made the best over-all improvement, indicating that there were likely to be other secondary drivers to consider as the treatment continued.
Seated trunk rotation (STR)
The task of STR was chosen as thoracic rotation is an important component of running. I wanted to look at available range of motion bilaterally and I find it easier for the patient to gain a sense of restriction points when sitting, rather than the standing ‘full body twist’. I was also considering its use for homework as it is easily reproducible and measurable for the patient.
In sitting, the pelvis was rotated to the right (TPR(R)) a change from when the patient was standing. She sat on an ‘unlocked’ pelvis which means that relative motion was palpated between the sacrum and innominate bones, indicating that the pelvis was not transferring loads appropriately prior to/into the task of sitting.
She had more restricted motion in right STR than left. The best correction for this task was the TR3 and TR4. In sitting TR3- translated to the right and rotated to the left. TR4- translated to the left and rotated to the right. TRs 3 and 4 were ‘glued’. TR5- translated to the right and rotated to the left. This was positionally the same as in standing. As the patient rotated to the right, the 3rd and 4th rings remained shifted. By partially posteriorly rotating the left rib of the 4th ring, waiting, monitoring and de-rotating the 3rd ring in response on the right, the rings were held in a more neutral position. Because they were ‘glued’ correcting one ring would impact the other, making it worse. The correction was performed in sitting and the range was assessed (to be better). The correction was then performed again in standing, and held as the patient sat again. More rotation was obtained by correcting the rings prior to sitting as the correction improved the pelvis, hip and lumbar spine position before the STR task was started.
Correcting the upper thorax revealed a very strong vector visceral vector (pulling towards the heart). A vector can be deep, or superficial, short or long and the nature of the pull can help us to determine what structure is likely to be causing it. In this case the pull was felt to be originating deep into the chest on the left side.
Correction of the cranium did not improve the cervical spine or clavicles. Correction of the cervical spine partially improved the clavicles, but did not improve the task. Correction of the humerus did not improve any other sites of sub-optimal performance. (I did not note and can not recall any specific impacts on the cranium on this occasion).
A technique called ‘listening’ was used to establish a possible vector acting on the upper thorax.
The best corrections for quiet standing, STR and OLS were found to be thoracic rings 3 and 4. The ‘correction’ is applied by gently distracting the rings and ‘creating space’ in between them, the anteriorly rotated rib is then posteriorly rotated whilst monitoring the other rib of the ring and the rings above and below on the opposite (and same side) of the thorax. A full correction is achieved when optimal alignment is palpated and the task is improved in terms of ease, quality of movement, pain and range of motion. When the correction is slowly released the therapist can monitor through their hands for where the vector of pull is originating (passive listening).
The primary and immediate vector palpated was visceral and was thought to be originating in the heart and left lower lung/diaphragm.
It was difficult to correct the rings fully, however they produced the best over-all correction of the other sites of sub-optimal performance. It was decided that the first line of treatment would be to treat that vector. Anatomically the fibrous pericardium is attached to the cartilages of the 3rd to the 7th ribs on the left and to the central tendon and muscular fibres of the diaphragm. The patient has a history of physical trauma to her left lung (lung collapse and pulmonary embolus) and emotional trauma (P.T.S.D.). In Chinese medicine the lungs are the organ of grief and in cranial-sacral therapy the respiratory diaphragm is said to be potentially affected by physical and emotional trauma, with that in mind I felt there was sound clinical reasoning to initiate treatment. The correction (passively at this point) of TRs 3 and 4 improved her pelvic control and corrected her right hip. With the rings corrected passively (anteriorly by the patient) she transferred weight onto her right leg without her right SIJ unlocking, pain-free and with perceived ease of control by the patient.
The vector connecting the left diaphragm, heart and third and fourth thoracic rings (fibrous pericardium) was released with the patient in supine lying using release with awareness (RWA), fascial release techniques and directional breathing. We used a verbal ‘cue’ visualising and creating a sense of deep joy. The patient can use whatever imagery helps them to create and focus on the joyful feeling. It is not necessary for the therapist to know which image they choose. This patient easily identified an image, others may need examples and may take longer. We then progressed to ‘ring, stack and breathe’ (RSAB) a technique developed by Dr. Linda-Joy Lee. The driver rings are corrected and held (in this case by the therapist) whilst the patient takes six deep breaths. Each deep breath is inter-spaced by relaxed breathing. The patient is asked to direct the breath to the relevant section of the thorax, in this case the anterior upper thorax. RSAB can release multiple vectors connecting to the thoracic rings and is an efficient way of ensuring optimal release prior to further treatment. This treatment improved, but didn’t resolve the glued rings. The 4th ring was perceived as the primary driver with the 3rd ring compensating for it.
At this point the patient still needed to passively control TRs 3 and 4 externally, however they became easier to correct. Even with some release of the deep visceral vector, it was not totally released which meant that the patient needed to practice some release techniques at home to try and maximise the impact of the initial treatment.
The patient was taught how to manually self-correct the third and fourth thoracic rings anteriorly. Initially it was advised to do so in supine lying to optimise relaxation and reduce some of the compressive effects of standing. They were given the home-practice to try and eventually gain the correction using imagery only, if possible.
The connect component relies on the use of the deep system. In this instance the patient was using a deep cue to connect and engage her intrinsic muscles (thoracic/segmental multifidus, levator costarum) locally to the 3rd and 4th thoracic rings. We used palpation into the segmental multifidus laterally at T3/4 specifically to help her brain to recognise exactly where to engage. Pain can cause a delay in the anticipatory contraction of the deep muscles. If this muscle contraction delay/absence is not corrected, the dysfunction can remain. You cannot strengthen a muscle that your nervous system isn’t using, therefore it is important to ‘connect’ to this system prior to or along-side re-training movement (Diane Lee, Diane Lee and Associates).
The initial movement regime was separated into progressions. I anticipated a likely need for significant release over subsequent treatments with the primary vector being visceral. And additionally there were likely to be neural/dural vectors. My treatment approach was therefore very gentle.
To ‘capture’ the dural system we placed a small rolled towel under the sacrum. Feet were to be placed on a wall to prevent supination. The patient then slowly and gently flexed the head and neck to create a gentle dural stretch. The progressions were to add the use of her upper limbs by attempting to control the 3rd and 4th thoracic rings whilst raising her upper limbs to 90 degrees. She could then add knee rolls (all the time controlling the rings and using breath to release any vectors) subsequently taking the correction into sitting, and then standing.
Ms. A is not local to the clinic, we had therefore agreed to liaise over the internet to monitor progress and discuss any issues that may arise. We spoke just over a week after the initial assessment and treatment. She reported that her low back pain had improved a lot, but that she was getting some coccyx/pelvic floor pain and some left plantar fascia pain with walking.
I had omitted to assess the position of her coccyx at her first assessment, so I asked her to do this herself. She felt that it was deviated to the left. I hypothesised that her coccygeus muscle may be tight in response to us not monitoring it during the dural stretches. I asked the patient to gently correct the coccyx whilst thinking of her cues for her thoracic rings, then to step forwards. She reported that the foot pain was resolved with the coccyx and thoracic correction. We know that the third and 4th thoracic rings were poorly controlled and ‘glued’. Iliocostalis attaches posteriorly to the ribs and ilium, and if acting or reacting can compress the SIJ and cause dysfunction. In this case Ms. A’s pelvis was rotated to the left ((L) TPR) which worsened with weight transfer onto the right lower limb. We could hypothesise that when walking, increased tension and torque would occur at the knee, which could irritate the posterior tibial nerve. We could also hypothesise that the left coccygeus had increased in tone as a reaction to the pelvic TPR/IPT which was why on palpation it felt tight and sore.
We agreed on the following revised treatment plan:
- Release: Left coccygeus (manually first and then with imagery)
- Align: Thoracic rings 3 and 4 and coccyx.
- Connect: Cue to relax the pelvic floor and to connect to the ‘deep system’ at thoracic rings 3 and 4.
- Move: Step forwards (if easy and pain free continue for 30 reps, if possible).
Ms. A continued to have intermittent ‘flares’ of her pain for a few weeks, although the pain had improved to the point that she had been able to reduce a lot of her regular analgesic medication. We are continuing to work on the control of her thorax, and have also been working on coccygeus cues as her pelvic floor reacts quickly if she either pushes the dural release too hard or sits on a hard chair/surface for too long. The plantar-fascia pain has not returned. We are still taking note of any changes that occur with her ability to perform the exercises and her pain levels when her orthodontic braces are adjusted. Ms. A has also had to spend some time managing her stress levels and coping with the variation in her pain. We discussed not panicking if her pain levels increase, as in the past she has always tended to rush to have manual treatment straight away. She now has the ability to self-correct more easily which will enable us to add ‘layers’ to her treatment each time she visits the clinic.