Stefanie DiCarrado

When the pelvis is rotated in the transverse plane to the left, it is often associated with a left intrapelvic torsion (IPT). What is the difference in relative position of the sacrum to its innominate between an unlocked SIJ and an IPT?

The sacrum should always be in a nutated position relative to the innominates for optimal load transfer. When the pelvis is rotated in the transverse plane, one side of the sacrum should nutate slightly more allowing the sacrum to rotate in the same direction as the pelvis. If an SIJ is unlocked, that tells us the sacrum is not rotating in the same direction as the pelvis or at the very least it is not rotating as much as it should be to maintain optimal alignment with the innominate. In a L TRP with a L IPT – the pelvis is rotated to the left in the transverse plane and so the sacrum would also be rotated to the left (and slightly more nutated on the R as relative to the R innominate).

The left side of the sacrum should also be nutated relative to the left innominate. Because the left innominate is posteriorly rotated relative to the right innominate it rotates the sacrum to the left so it ‘appears’ like the sacrum is less nutated on the left. However, since the innominate has posteriorly rotated on the left, I think the amount of nutation on both sides can be close to the same amount. Regardless, you are right – both sides of the sacrum are nutated relative to their respective innominates.

You are correct – this is a highly compressed thorax with one regional ‘sandwich’ or rings rotating in alternate directions (TR7,8,9) and 3 other rings not stacked (TR4,5,6). No one ring correction is going to change this!

Are you saying that when Ms. L elongated her thorax her neck flexed and left sidebent or are you saying that this is a common finding?  Please clarify if this did happen for Ms. L and even it did not, what is your hypothesis as to why lengthening of the thorax would create shortening of the neck, and how would this potentially change the direction of your assessment?

When asked to “sit up straight” for autoelgonation prior to this evaluation, cervical flexion always occurred and a left cervical sidebend sometimes occurred. In this particular instance, both cervical flexion and a left cervical sidebend occurred.

What is your hypothesis (that you have already suggested in her story) as to what could be caused the flexion/sideflexion of the head and neck to occur when she elongates her thorax and how would you test this hypothesis? Did you happen to notice any change in the horizontal level of her eyes (not relative to the neck but intra-cranially)?

My hypothesis was related to the buccopharyngeal fascia, that when she elongated her thorax, the esophagus (enveloped by a continuation of the buccopharyngeal fascia) elongated and pulled on the buccopharyngeal fascia. The fascia forced the left cervical sidebend and cervical flexion may have occurred for the same reason but I felt it had more to do with its position in the retropharyngeal space. If it was purely a left buccopharyngeal restriction, then I think only a left sidebend would occur. Since there was cervical flexion with a bias toward the left, I think both sides have a restriction in the cervical spine, but the left side also has a restriction that goes up toward the sphenoid. During this specific session, I do not believe I noticed any change in the level of her eyes, but in subsequent sessions I did notice a worsening of the left sidebend of the sphenoid when correcting her thoracic rings.

To be clear, was the change from the sitting unsupported position to the sitting auto-elongated position of the rings, the following:

TR 8 & 9 stacked in the elongated position TR7 remained right rotated (a single ring impairment)

TR5 & 6 remained left rotated, TR4 remained right rotated (a 3 ring impairment)

Yes, that is exactly what the elongated posture revealed

To be clear, correcting the alignment of TR4,5,6 restored full control of both SIJs in the squat to sit task and the LTPR. If the pelvis corrected, it makes total sense why the right hip and lumbar spine corrected. Why?

The lumbar spine and hip were congruent with the pelvic TPR and likely being pulled along with the pelvis as it rotated. Anything correcting the pelvis would correct the hip and lumbar spine as well. I was not able to manually check the SIJ while manually correcting the rings but the improvement in the pelvis, lumbar, hip position, overall thoracic position and subjective experience lead me to believe there was a restoration of SIJ control.

Any ideas yet what structure lies “inside the thorax” and becomes the pretracheal/buccopharyngeal fascia in the neck?

The primary driver for FU#1 was therefore determined to be the thorax with TR4 (RR) and TR 5&6(LR) as the priority rings with TR4 glued to TR5&6 and TR5&6 appearing compressed. TR6 was left rotated to a greater extent than TR5.

Only partial corrections were possible for these three rings which indicated the need for an articular assessment, but during the correction, a very strong long vector was noted from within the thorax itself.

There is another impairment/vector that I am thinking about here that could result in worsening of the head/neck when the thorax is corrected and it’s not the articular system. Any idea?

The main impairment/vector that jumps out at me is the buccopharyngeal fascia and/or a neural vector having to do with the vagus nerve.

YES YES YES!!! Think of a vector from the pericardium/pretracheal/buccopharyngeal fascia like the dural system impairment. No MSK driver can be found since every regional correction makes something else worse. This vector has to be treated first, even before any articular assessment. You don’t have a MSK driver here since correcting the thorax worsened the neck and head.

Here is your evidence that the buccopharyngeal fascia is involved – it is what commonly sidebends the sphenoid and creates the vector that behaves much like the dural system impairment limiting auto-elongation of the thorax without compromising the neck/cranium.

To understand the findings below, were they done in the auto-elongated position (a correction as well) in which TR1 & 2 correction occurred, or her habitual sitting position?

These were done in her habitual sitting position.

Did correcting the cranium restore C2 and C7 alignment? You note that the patient was able to elongate her neck and hold a more neutral position so I suspect something more than control happened to the cervical segments.

C2 and C7 were partially, but not fully corrected, by correcting the cranium. I was able to palpate C2 while correcting the ICT with both hands but to palpate C7, I had to use one hand to correct the cranium, so I question my effectiveness. C2 was mostly corrected but not fully corrected when correcting the cranium. I also used her ability to elongate her neck and hold a more neutral position as evidence that there was an improvement in alignment of the cervical segments. Ms. L was unable to move her arms up to her neck to monitor these segments herself.

Did the co-correction of C2 and C7 change the gagging sensation as well as the co-correction of the sphenoid and ICT? Where do you think the pull down into the diaphragm is coming from with this correction? Hint: the sidebent sphenoid is also likely being impacted by this vector of force and one of the reasons why I would choose the cranial region as the primary driver here.

Yes, my apologies for not specifically stating that – C2 and C7 co-correction resulted in the best subjective experience which included the resolution of the gagging sensation and even air hunger as well. The buccopharyngeal fascia is the vector to which I believe you are referring. I was always bouncing between a cranial or cervical primary driver for this patient. She certainly appears as a cranial driver, but I found if I started with the cranium, the releases would take a lot longer and at times would cause discomfort in the cervical region so that I would have to stop, address that and then return to the cranium. At times, starting in the cranium without first addressing some cervical vectors between C2 and C7 would result in an autonomic event where she would become flushed, begin gagging and eventually vomit, then break out in a sweat. It would take at least 10 minutes to calm her system down before we could work again. I believe this has something to do with the buccopharyngeal relationship to the pre-vertebral fascia and perhaps the impact her cervical dysfunction had on the vagus nerve. The cervical spine seemed to be pulled by both the cranium and the thorax, but it seemed like I had to “unstick” the fascia there in order to address the other regions. However, this could be because I am a novice that is learning about these vectors and perhaps this is truly a cranial driver and I just wasn’t quite correct in my treatment interventions.

This is exactly my experience with the pretracheal/buccopharyngeal/pericardial fascia vector – it is a complex one that often requires local release (as you note above) before the full line (sphenoid to diaphragm) can be addressed.

There is another visceral connection, other than the pretracheal/buccopharyngeal/pericardium we have been discussing that can explain why trying to manually correct TR1worsened the gag sensation. What structure attaches to the lung and the first rib and is in continuity fascially with the mediastinal structures?

The continuation of the buccopharyngeal fascia that enters the thorax is the parietal pleura. This is also considered a layer of the endothoracic fascia which distally blends with the fascial of the diaphragm and forms the phrenico-oesophageal ligament. This ligament is thought to have an influence on the lower esophageal sphincter. I should note that, subjectively, this patient very often would report feeling like food would get “stuck” right above her stomach. More proximally, this fascia attaches to both the first rib and to C7’s transverse process. It also blends with the pre-vertebral fascia and the phrenopericardial membrane. This is all becoming so clear now!

And the parietal pleura attaches to the first rib and C7 via the suprapleural membrane.

I would switch this up! My feeling is that treating the vector that is sidebending the sphenoid (it likely goes to the diaphragm) first would allow her to elongate so much easier. I’d do this before the cervical spine. Thoughts?

I’m inclined to agree based on the findings, but in practice I found that if I addressed the cranium 1st without addressing the cervical spine, her system would not respond as well. I believe her buccopharyngeal fascial restrictions, maybe even cervical instability may have led to a sensitized vagus nerve which required me to first work in her cervical spine, specifically addressing the pre-vertebral fascia. Considering the retropharyngeal space has the buccopharyngeal fascia anteriorly, the carotid sheath with the vagus nerve running laterally, and the pre-vertebral fascial posteriorly I think there was this lack of fascial gliding this cervical area exacerbating dysfunctions in the thorax and cranium. It was interesting because I would treat her cervical spine until a vector or her subjective reports would then lead me to the cranium. Then I could fully clear the vectors in the cranium and then would need to return to the cervical spine where I could then completely clear those vectors.

I don’t think we can identify a MSK driver in this case. Every correction made something else worse, and yes her best experience was with the cervical correction (her gag response was least); however, her head sidebending worsened. As mentioned above, I think this visceral system vector is compressing the entire MSK system from the cranium to the diaphragm, and maybe even lower, and needs to be treated exactly as you have described above before any MSK driver can be found – very similar to a dural system impairment. The pharyngeal plexus (CN IX and X) supply the upper and lower part of the buccopharygeal fascia so your hypothesis of the vagus nerve being involved is supported by the anatomy.

This is all so fascinating – I didn’t think to look into the neural innervation of the buccopharyngeal fascia.

All of this is further evidence that the musculoskeletal system cannot ‘stack’ and align in the presence of this vector.

In ISM the purpose of finding a driver is to determine the underlying system impairment requiring treatment. There are some system impairments that reveal themselves by not permitting correction of anything without significantly worsening another body region. I think this is the case you have here. It is very clear to me that the first impairment to treat is the visceral vector from the sphenoid to the diaphragm and that it will require local releases (cervical before cranial) before tackling the entire vector.