In September 2022, Mrs B presented to the clinic for an initial assessment and treatment. She chose to come to the clinic as she was an avid CrossFitter who was a former high level CrossFit master’s athlete. At the time of the assessment, Mrs B was a 53-year-old woman with two children. She was aware of my own background in the sport and knew I would not dismiss her based on how she chose to exercise. She mentioned it being difficult to find therapists over the years as they would often lecture her about the level and intensity of training she did at her age. I was recommended by several people from the gym she attended due to my approach to assessing dysfunction.
She came to the clinic two weeks after injuring her lower back during a Crossfit session. She had been participating in a Crossfit workout for approximately fifty minutes, when the injury occurred. She described feeling ok prior to and during the workout, she added that she was tired from work that day. She said this feeling would normally pass once a workout started. However, in this case, it did not. During the last repetition of a deadlift movement in the workout she felt her lower back go into a spasm, and she felt as though her left side from the pelvis up to her mid back locked up. She tried to stretch it out after the workout; however, this provided limited relief and did not ease the spasm. She felt no numbness or tingling. The pain was localised to her lower back and up into the left side of the thorax.
Mrs B went home, rested, and put some heat on her back. The next day, she felt better; however, her lower back felt tender and between her shoulder blades felt extremely tight. She no longer felt as though they were connected i.e., the mid thorax and lower back felt separate. The pain eased in the lower back over the coming days. She described her whole spine generally feeling tight, from her head to her pelvis. She decided to wait until she saw me before she trained again as she was rattled by the injury to her lower back.
Mrs B said she always strived to move well and worked hard to ensure she only did things her body was capable of. She did not believe in “muscling through” workouts. Having experienced ridicule from peers for doing CrossFit, she took pride in the fact she remained relatively injury free.
Prior to the flare up, Mrs B had not suffered from any lower back injuries during Crossfit. Mrs B had previously experienced an ever-present tightness in her right shoulder that got worse the more she trained. She had seen other therapists and practitioners; however, they were unable to address the issue. She would receive routine treatment via soft tissue work to manage the tightness and pain that built up over a period of training. Although it became painful, she said it never felt like an “injury”. During her CrossFit Games preparation, she received treatment weekly to ensure she was not distracted by it. She was given multiple different reasons as to why it was a problem, but no one had ever been able to relieve it completely. Since ceasing high level competitive CrossFit a few years prior, she found she could manage it with stretching and mobilising in order to train, though it never went away. Additionally, she would get a “tune up” now and then if it got out of her control.
Mrs B said that in the lead up to this workout, she had been very stressed at work. This was an unusual amount of stress for her. She also admitted her training had decreased due to the stress over the last couple of months. The stress had also affected her sleep and she was aware that she had been clenching her teeth a lot. She knew this as she could feel her jaw was tight upon waking and would need a few repetitions of opening before the tightness would subside. She mentioned this was a habit she had developed in her twenties. However, until the work stress had started a few months ago, she had managed to break that habit. Or at least she wasn’t aware of any tightness in jaw upon waking until recently.
Mrs B’s medical history included a c-section 17 years ago and she also had a laparoscopic surgery for a left ovarian cyst removal 2 years prior. Her only other complaints were the previously mentioned right shoulder issue that would often lead to golfer’s elbow in her right elbow if she engaged in a higher volume of training.
At the initial assessment, Mrs B’s primary complaint was lower back weakness when bending or hinging forward and feeling stiff in her mid-thorax. She did not feel comfortable with the idea of loading her lower back into flexion or squatting.
Mrs B wasn’t sure why she had hurt her back, which reduced her confidence. She believed she was likely to do it again and was fearful of going back to training or loading her back. She had the cognitive belief that her body was no longer capable of training hard. Therefore, she was worried her body wasn’t capable of Crossfit anymore and felt quite deflated as a result. The injury has taken away the self-assurance that she was capable, and she had lost belief in her body’s ability to perform. She said she suddenly felt old.
Mrs B’s goal was to ease back into training without fear of injuring herself again. As the injury occurred during a Deadlift movement, I decided this movement would be the screening movement for the session.
Considering her recent flare up of symptoms, and her cognitive beliefs, I conducted the screening task unweighted. Mrs B essentially mimicked holding onto the bar, her body was in the same position she would be when she carries out this movement in the gym. She felt safe enough during this movement to be able to be assessed.
Functional Unit #1
Standing Start Screen
Mrs B had no symptoms in the standing start screen position. The standing start screen helps to establish the baseline position of the body before the screening task related to the meaningful task is assessed. This makes it easier to establish which findings are relevant and which are not. Hence, finding the findings. As every patient is an individual, we must treat them as such. Having a baseline assessment helps to establish objective findings in that patient at that time. This helps to prevent therapist driven bias’s coming into the assessment that might cloud the assessment process.
We cannot assume, as therapists, that all findings are relevant. No one body will stand in perfect alignment, and our job is not to create this. Our job also isn’t to simply pick out faults in the patient. To quote A.T. Still, “Anyone can find disease, to find health should be the object of the practitioner”, (Lewis, 2016). Any findings we do find must then be assessed in a way that is relevant to the patient. Therefore, we are looking for any non-optimal biomechanics for the patient relevant to their meaningful task.
Pelvis: The pelvis was in a left transverse plane rotation (TPR) with a congruent left intrapelvic torsion (IPT)
Hips: The left head of femur (HOF) was anterior to the left acetabulum. This is an incongruent finding relative to the left transverse plane rotation of the pelvis.
Lower Thorax: The lower thorax was generally right rotated in the transverse plane.
The 10th thoracic ring (TR10) was translated left and rotated right, which is an incongruent finding relative to the pelvis. The 8th thoracic ring (TR8) was translated right and rotated left. This was an incongruent finding relative to TR10. The 7th thoracic ring (TR7) was translated left and rotated right. This was an incongruent finding relative to TR8 and the pelvis. The 5th thoracic ring (TR5) was translated left and rotated right, incongruent to TR8 and the pelvis.
Lumbar Spine: The 5th lumbar vertebrae (L5) was rotated to the right relative to the pelvis. This was an incongruent finding relative to the pelvis.
The 4th lumbar vertebrae (L4) was rotated left.
The task I chose to assess any change in findings from the standing start screen was an unweighted deadlift or hinge motion. This was the movement Mrs B was doing when she injured herself and was therefore the most meaningful to her and relevant to her cognitive beliefs.
An optimal hinge strategy for the deadlift involves both innominates remaining posteriorly rotated relative to the sacrum. The pelvis should remain neutral in the transverse plane. The femoral heads should remain centred throughout the task. The hindfoot, should start in neutral alignment if moving from standing into the hinge. They will pronate and supinate as the knees flex and extend in and out of the movement. The lumbar spine, thorax, cervical spine, and cranium should also remain neutral through the movement. The shoulder girdles should remain neutral, and the humerus will flex and extend as the bar moves around the body.
In this task, I felt it was best to assess the patient from standing and then hinging into the movement. Normally the deadlift starts by picking the bar up from the floor. Mrs B said that she felt pain when she was lowering the bar, not lifting it. Therefore, it was in the eccentric phase of the deadlift, which starts from a standing position into a semi squat.
Given Mrs B could stabilise in standing, I needed to assess at what point in the task her body could not maintain optimal alignment and biomechanics. This occurred very early in the task, assessing from the bottom position of the movement would provide false negatives or at least unclear findings.
Pelvis: During the task the pelvis remained in a left TPR and the left SIJ unlocked (lost control). This happened at a point 20% into the task.
Hips: The left HOF moved further anterior relative to the left acetabulum. This continued to be an incongruent finding relative to the left TPR of the pelvis. The increase in femoral head translation occurred just before the unlocking of the left SIJ.
Lumbar: L5 increased its rotation to the right when the left SIJ unlocked. L4 also increased its rotation to the left as L5 rotated to the right.
Thorax: The lower thorax remained right rotated in the transverse plane. TR10 increased its translation to left and rotation right relative to the pelvis.
At this point I had three incongruent findings to work with (the left hip, the pelvis ( TPR & left SIJ unlock) and the lower thorax (TR10). I first corrected the left hip as it gave way before the left SIJ unlocked. Correcting the left hip restored control and alignment of the pelvis and alignment of TR10. Correcting the left hip did not correct the lumbar segments (L5 & L4) fully, L5 and L4 still rotated incongruent to each other but later in the task now. The task experience felt better to Mrs B, but her body position did not look good, she rotated more to the right in her upper thorax and cranium.
Correcting the left hip did not correct TR8. TR8 remained translated right and rotated left during the task. It did not change position when tested in the movement. I noted that correcting the left hip however improved TR7 and fully corrected TR5 in the upper thorax.
The left hip, so far, was the best overall correction of the corrections for the thorax in FU1. However, correcting the left hip did not make a change to TR8. When I partially corrected TR8 it corrected TR7, but this correction did not change the left hip in the task. TR8 was the best choice of thorax corrections but was a secondary driver.
The correction at TR8 was only a partial manual correction and it felt like there was an intra-thoracic ring articular restriction. I would need to mobilise any articular restrictions within TR8 to assess if it really was a secondary driver in the thorax and to assess if changing the osteokinematics of TR8 could potentially change the neural drive to the lumbar spine or left hip. Currently, the manual partial correction of TR8 was not changing the left hip. Also, when correcting TR8, Mrs B did not look or feel good. So rather than stop there I chose to continue with the assessment as I felt it was unlikely TR8 was the primary driver. Had Mrs B looked and felt good with the TR8 correction I would have stopped there and treated any articular restrictions within TR8 that needed to be treated. Then I would have gotten Mrs B up again and re-assessed.
Driver for Functional Unit #1
In relation to the findings at the lumbar spine, correcting the left hip improved the lumbar spine but did not give a full correction. Therefore, the left hip had the best overall correction for everything in FU1 except for TR8. A partial correction of TR8 and the left hip did not give a better correction than the left hip alone to the task or to the lumbar spine. In ISM, there are no manual corrections for the lumbar spine. The lumbar spine was also a secondary driver as there was no full correction of the alignment and biomechanics of the lumbar spine by correcting the primary left hip driver or secondary thorax driver. Therefore, the lumbar spine was also a secondary driver.
At this point I had a primary left hip driver, with a secondary thorax and lumbar driver.
Mrs B’s lumbar spine was still giving way under load, although later in the task. With the left hip corrected it felt better to Mrs B, but the body positioning didn’t look right in the task. When I corrected the left hip, it made the upper thorax worse and increased the TPR of the shoulder girdles. This also increased the right rotation of the cranium. A left hip and thorax correction with TR8 also made the upper thorax, shoulder girdles and cranium look worse. Mrs B could also feel this as she went into the movement, hence why I chose to leave TR8 alone for the time being.
Therefore, I felt it was relevant to continue into FU2 to see if there was a better correction from another site of impairment in FU2 that made Mrs B look and feel better than what I had found in FU1. The change to body regions in FU2 with a change to the findings in FU1 would indicate there was a relationship between these regions that needed further investigation.
A quick screen for cervical rotation showed it was restricted to the left.
I used this as a quick screen to objectively assess the impact of correcting the FU1 drivers on FU2. If there had been a complete correction of cervical rotation, it could be hypothesised that the FU1 driver is also the best overall correction for FU2. Then I would move to FU3. Although based on what I saw from the FU1 corrections, this seemed unlikely. When I corrected the left hip in standing, not the deadlift position, it worsened the cervical rotation to the left. This confirmed my choice to continue into FU2 as there seemed to be a relationship between the functional units. The correction of the left hip had a negative impact on the alignment and biomechanics of the body regions in FU2, meaning the left hip was not the primary driver for the overall task. It was the primary driver for FU1.
Functional Unit #2
Standing Start Screen
Cranial region: The cranium: Right intracranial torsion (ICT) with an incongruent left rotated sphenoid. The sphenoid position was assessed from the front of the cranium by palpating the greater wing of the sphenoid on the left and right side and visually assessing the position of the left and right orbits relative to the rotation of the cranium. The first cervical vertebrae (C1) was left rotated. This is also incongruent to the ICT. The 2nd cervical vertebrae (C2) was right rotated/left translated.
Cervical Spine: The 7th Cervical vertebrae (C7) was translated right and left rotated. This is incongruent to the ICT and C2.
Upper Thorax: The 2nd Thoracic Ring (TR2) was translated left and rotated right. The 1st thoracic ring (TR1) was left rotated. This was an incongruent finding relative to TR2.
Shoulder Girdles: There was a left intra-shoulder girdle torsion (ISGT). The head of humerus (HOH) were congruent on either side. This is an incongruent finding relative to TR2.
Summary of congruencies:
ICT, C2 and TR2 are right rotated.
Sphenoid, C1 and C7, TR1 and SGs are left rotated.
During the task, the right ICT of the cranium increased, and the sphenoid remained incongruent in left rotation. TR2 increased its right rotation as did C2. The shoulder girdles remained the same in a LTPR while TR1 rotated to the left. I used these findings to determine where the driver was in FU2. I noted that the cranium and upper thorax were rotating to the right during the task. Given TR2 was rotated to the right and the next incongruent finding relative to the pelvis I corrected it first.
I found that when I corrected TR2 it did not correct TR1, the cervical spine or cranium or the task. The TR2 correction did, however, correct the shoulder girdles.
As the cranium rotated to the right along with C2, I tried C2 as the next correction. This made no changes below and left the cranium in a RICT and made no change to the task. When I corrected the Cranium itself (co-correction of the sphenoid and ICT), it gave a full correction of the cervical spine and TR1 and the shoulder girdles. The cranial correction however, only partially corrected TR2.
Driver for Functional Unit #2
The cranial region was the primary driver for FU2 with a secondary thorax driver at TR2.
Drivers for FU1 and FU2
FU1 PD Left Hip, SD Thorax (TR8?), and Lumbar spine
FU2 PD Cranial, SD Thorax (TR2)
Priority between Unit Drivers
I found the cranial correction partially corrected the left hip (the anterior translation occurred later in task). The lumbar spine still gave way with the cranial correction but closer to the end of range and TR8 remained the same. The correction of the left hip did not correct the cranium; it made it worse. The left hip correction alone also worsened TR2 and the cranium.
The TR2 correction alone did not change the left hip or lumbar spine or TR8, therefore it was a secondary driver in the overall task as well as FU2. When I corrected the left hip with a cranial correction and TR2 correction it gave the best correction to the task so far. This correction also gave the best correction to the lumbar spine at this point as well, it was the latest in the task that it had given way. However, as the lumbar spine still did not fully correct it was still a secondary driver in FU1.
The left hip, cranial and TR2 correction did not change TR8. it also remained as a secondary driver in FU1.
For the patient, both the look and feel during the meaningful task were the best with the left hip, cranium and TR2 corrected. Therefore, they were the best overall corrections for FU1 and FU2 so far.
Summary of unit drivers
Primary driver for the task: FU1 Left Hip and FU2 Cranial Region
SD for task: FU1 Thorax (TR8), Lumbar spine and FU2 Thorax (TR2)
At this point I had to ascertain whether these were also the best corrections for FU3 as I had noted the left foot had pronated in the task. The left elbow was also more flexed during that task.
Before assessing this I did a quick test with my corrected findings so far. With the co-correction of the Cranium/thorax and hip I noted that these corrections corrected the left foot and the left elbow in the task. Although the task was unweighted, the testing position mimicked the position of the wrist and while holding onto the bar. The task may have been different with a weighted bar in the Mrs B’s hands for the both the elbow and the foot. However, I had a good correction of the task, the left elbow, and the left foot with the co-correction of the left hip, thorax (TR2), and cranium. I was happy to move on in this session.
The Cranial Region: Cranium
Further assessment of the cranium was done using an active and passive mobility test. As the movements of the cranium are involuntary or passive, it is not necessary to test the active control and passive control of the cranium.
Active Mobility Test
From the work of W.G. Sutherland, it has been theorised that the bones of cranium move in the living organism, (Barral and Crobier, 1999; Liem, 2004; Surgueef, 2007; Sutherland, 1990; Stylian, 2022; Upledger and Credevoogd, 1983). This movement is palpated as a rhythmic cyclic phenomenon called the primary respiratory mechanism, (Barral and Crobier, 1999: Liem 2004; Surgueef 2007: Sutherland, 1990; Stylian, 2022). It is divided into two phases: inspiration and expiration. During inspiration, the midline unpaired structures of the skull and move in the direction of the foetal curve as the nervous system coils; this is named cranial flexion, (Surgueef 2007: Stylian, 2022). The paired structures, for example the temporal bones, move in external rotation, (Surgueef 2007: Stylian, 2022). During expiration the midline structures move in the direction of craniosacral extension, while the paired structures move in internal rotation as the nervous system uncoils, (Surgueef 2007: Stylian, 2022).
The movements of these bones can also be felt and seen during movement, (Lee, 2018). As such it is necessary to assess how and when the cranial bones move during the meaningful task, if it is a driver. This is achieved by assessing the anterior and posterior rotation of the temporal bones and the position of the sphenoid during the task. For the purposes of keeping consistent language within ISM, the terms for motions of the cranial bones have been replaced so that they are like the pelvis. Therefore, the cranial motions are as follows:
a) Anterior rotation (ISM) = external rotation (Osteopathy)
b) Posterior rotation (ISM) = internal rotation (Osteopathy)
a) Nutation = flexion or inspiration of the skull
b) Counternutation = extension or expiration of the skull
Mrs B’s cranium began in a right ICT with an incongruently left rotated sphenoid. The left temporal bone was anteriorly rotated relative to the right which was posteriorly rotated. During the deadlift task the right temporal bone moved further into posterior rotation and left temporal bone into further anterior rotation. The sphenoid remained rotated left relative to the temporal bones.
An active mobility test of the cranium involves rotating the cranium left and right to end range head and neck rotation to assess the motion of the temporal bones in the transverse plane. At the end range of head and neck rotation there should be rotation of the temporal bones relative to the direction of rotation.
In Mrs B’s case there was no posterior rotation of the left temporal bone when she turned her head to the left. Similarly, there was limited anterior rotation of the right temporal bone when turning left. This coincides with the restriction of left head and neck rotation noted in the screen for head and neck rotation during the quick screening task.
Passive Mobility Test
The passive mobility test is used to assess the ability to de-rotate the temporal bones and sphenoid and bring the cranium into a neutral position. It is also used as a passive listening test to assess what vectors of pull are acting on the cranium. This helps to determine whether the vectors acting on the cranium are intracranial or extracranial. This test involves distracting the temporal bones laterally and then bringing each temporal bone into a neutral position relative to the ICT. As the sphenoid is incongruently rotated to the ICT, it is also necessary to bring the sphenoid into a neutral position relative to the temporal bones. Then a release and listen is performed to ascertain which bones moves first and where it gets pulled to.
Figure 3a – Superior attachment of the pharyngobasilar fascia (Barral and Crobier, 1999)The third finger of the left hand was used to direct the sphenoid out of left rotation by distracting the left greater wing of the sphenoid from the left sphenosquamous suture.
Then, the left temporal bone was distracted and rotated posteriorly, while the right temporal bone was distracted and rotated anteriorly.
Upon release of this correction, the first bone to move, and thus the strongest vector, was on the left side of the sphenoid. The sphenoid was drawn back towards the left temporal bone into left rotation and nutation from an inferior vector coming from a caudal pull from pharyngobasilar fascia and even more caudally via the buccopharyngeal fascia towards TR2. This confirmed my thinking there was a connection between the cranium and TR2 that was deep to the muscular vectors that would normally affect TR2. The attachment and anatomy of this can be seen in figures 3a,b and figure 4a,b,c,d.
The second vector felt was the left temporal bone getting pulled into anterior rotation by the left temporomandibular joint.
There was also a vector felt acting on the right temporal bone as it moved into posterior rotation that was intracranial. I hypothesised this to be the right cerebellar tentorial membrane.
That concluded the assessment of the cranium as there were no further tests for the cranium.
These findings suggest the following structures would require release in the following order:
- Buccophragyngeal/Phrayngobasilar fascia vector
- Anterior Left cerebellar tentorial membrane at the posterior clinoid process
- Articular capsule of the left TMJ
- Right cerebellar tentorial membrane at the right transverse sinus
Further assessment of the left hip included active mobility, passive mobility, active control, and passive control tests.
As was noted in the screen task the left hip translated anterior relative to the left acetabulum and lost centre in the first 20% of the movement.
The left and right hips were palpated as the patient was taken through flexion, extension, adduction, and abduction in the position of loss of control noted in the task in standing. It could be felt that the hip did not want to extend or adduct very easily in this position. This is similar to the finding in the screening task confirming there are vectors acting on the hip as the hip loses control.
This was conducted in supine. The femoral head was palpated as the left hip was taken into flexion. This is similar to the screening task. In this assessment the femoral head translated anteriorly in the first 20 degrees of movement. This coincides with the loss of control during the task.
Once it was established where in the range of motion the femoral head lost centre, a passive listening test was performed to assess what vectors were acting on the left femoral head. After stabilising the left side of the pelvis, the left femoral head was manually translated laterally and then posteriorly, to centre the head of femur, and then this position was released to determine the location, length and strength of the relevant vectors. From this it was established there was a vector coming from inside the pelvis, in the pelvic bowl, that directed up towards the left ovary where a surgical scar was located. There was also a secondary rotational vector coming from obturator internus.
As the hip vector drew my attention to the abdominal pelvis I also used a Barral local listening test at the deduced point of termination of the vector. I found there to be a scar tissue restriction at an incision point from the abdominal surgery Mrs B mentioned in her story. The vector extended towards the sigmoid colon, and the sigmoid colon extends down toward the acetabulum, (Barral, 2005). The left ovary sits deep to the sigmoid colon, (Barral, 2005). This local listening test helped me to establish the connection between the hip and abdomen.
This was not conducted as there was nothing in the history indicating this test was necessary.
These findings suggest the following structures would require release in the following order:
- Intrapelvic vector coming from surgical incision site
- Obturator internus vector
Further assessment of TR8 was conducted as I suspected there were articular restrictions within this thoracic ring. This was deduced during the meaningful task assessment and in standing before assessing the left hip and cranium. As this was not a primary driver, I needed to screen this quickly and treat the relevant articular restrictions in the thoracic ring. Then I could assess its relationship in relation to the task and the drivers I had found so far.
I chose to do this after I had assessed the other functional units as a partial correction of TR8 was not indicating it was a primary driver.
The osteokinematics of TR8 were noted during the meaningful task. The 8th thoracic ring was held in right translation and left rotation. It did not change during the task. No other active mobility test was performed as the thorax remains neutral during the meaningful task. Had Mrs B had issues with running for example, I would use rotation as part of the active mobility test for the thorax.
The screening test ascertained that TR8 felt very stiff when trying to correct it. This suggested there was an articular system impairment as opposed to a visceral system or neural system impairment.
The articular system was assessed using the following tests:
a) Inhalation/exhalation while palpating the costotransverse (CT) joints at TR8. In the vertebrochondral region this is used to assess the anterior, lateral, and inferior (ALIF) glide of the CT joints in inhalation. Then the posterior medial and superior (PMS) glide of the CT joints in exhalation.
b) Flexion and extension of the thorax while palpating the 4 associated transverse processes of the zygapophyseal joints at thoracic ring 8.
The testing yielded a restricted right costotransverse joint in ALI glide. The right T7-8 Z-joint was restricted in extension, meaning there was a restriction in inferior glide of the 7th vertebrae on the 8th on that side. The left T7-8 Z-joint was restricted into flexion, meaning there was a restriction in superior glide of the 7th vertebrae on the 8th on that side.
During the meaningful task assessment, a partial manual correction of TR8 corrected TR7; however, it did not change at all during the task.
This was not tested as nothing in the history suggested this was necessary.
Releasing Beliefs and Gaining Understanding
Since Mrs B had come in with back pain that had been created by a back exercise, it was necessary to educate her as to why treatment of her cranium would be necessary to help her low back pain. For her, the cranial correction was the most confusing part of the assessment. Although she could feel her cranium was part of the meaningful task assessment, she still didn’t understand the why. Mrs B had noted stress as being a significant factor in the lead up to the injury, so she was open to the fact that it was somehow related. She had already heard of the methods of ISM assessment from other peers at the gym, so was intrigued, and not at all surprised, by the seemingly “outside the box” approach.
To help connect the dots, Mrs B was educated around the effects of the muscles of jaw acting on the cranium and the dural system both within and outside the skull, as well as the effects of the sympathetic nervous system on the dural system. I also showed her how muscles attached from the pelvis and lumbar spine and inserted onto the thorax. This helped piece together why we might have needed several corrections in the body to get a good correction for the task. I have found using visual aids quite useful in at least getting patient’s onboard with the idea of interregional connections.
At that point Mrs B was ready for treatment. Addressing the cognitive beliefs through education and explanation helped to put her at ease.
Thorax – TR8: Articular System
The articular restrictions at TR8 were treated first.
The 3 joint restrictions in TR8 were released using a vector-specific grade 4 sustained glide into their relative barriers of restriction e.g., restricted ALIF glide right CT joint, superior glide left Z-joint, and inferior glide right Z-joint. Essentially finding the “string in the spring” for each joint, until the articular barriers were released, (Lee, 2018). As mentioned in the assessment, there was a question mark over this thoracic ring’s impact on correcting the other drivers. After release, a quick screen was used to establish what had changed. It was noted there was now a dominant neuromuscular vector acting on TR8 that behaved in a similar pattern to the first screen. It allowed a full correction of TR7, but still did not change the hip and cranium as the best overall corrections. The left hip, TR2, and cranial correction also gave a correction of TR8. After this release; however, Mrs B noted she no longer felt tight in her mid-thorax, which was part of her story and meaningful complaints.
Due to an intuition from the story and assessment that there was a connection between the left hip and cranium via the deep fascial system, it seemed appropriate to treat the restriction in the left hip first.
Left Hip – Neural system
With the patient in crook lying the vector from the abdominal pelvic scar was released first by following the direction of resistance of the fascial barriers around the scar and into the pelvis. This was followed by a release of the sigmoid colon using the left leg as a long lever. While holding the visceral vector in the sigmoid colon the left femur was taken into extension until the barrier between them let go. As mentioned before, the left ovary sits behind the sigmoid colon, so this release made sense as being a barrier to hip mobility, (Barral 2007b). Vectors coming from the sigmoid colon can also have an impact on the biomechanics of L4/5 and L5/S1, which could explain the odd findings with the lumbar spine during initial assessment, (Barral, 2005; Barral, 2007b; Barral and Crobier, 2012).
The obturator internus vector was released in side-lying using an external trigger point release on the body of obturator internus where it sits over the obturator membrane.
Cranial Region: Cranium – Myofascial system
With the left hip vector released, a quick reassessment of the cranium with a passive correction/release and listen indicated the vector now had less caudal pull on the sphenoid and seemed to be more at the sphenobasilar symphysis.
The SBS was released by stabilising the occiput and taking the sphenoid into further compression with increased left rotation and nutation and waiting for a change. Stylian (2022) and Barral and Crobier (2019, 1999, 2007a, 2007b) agree that it is often better to take the barrier of restriction into a direction of ease before taking into a direction of tension. Once a change was felt, the sphenoid was taken into right rotation and counternutation while stabilising the occiput. The pharyngobasilar fascia attaches to the basilar part of the occiput, the lower part of the posterior sphenoid and to the petrous portion of the temporals, (Barral and Crobier, 1999). As mentioned by Barral and Crobier (1999), these superior insertions cross over the sphenobasilar symphysis, which explains the consequences of a caudal vector on the cranium.
A passive correction of the cranium yielded a vector from the left TMJ, impacting the left temporal bone. The temporal bone on the left was immediately drawn anteriorly on release. This remained after the release of the sphenoid, which was now congruent with the cranium. The left TMJ was release intraorally by mobilising the barriers of resistance in the articular capsule. The superior part of the lateral pterygoid attaches to the articular capsule and to the sphenoid, which can be treated by treating any articular barriers in the capsule of the TMJ, (Fernandez-de-las-Penas and Mesa-Jimenez, 2018;, Liem 2004). A fascicle of the masseter muscle was released along the posterior portion of the zygomatic arch.
The deep part of masseter attaches to the posterior one third of the zygomatic arch and to the articular capsule, which would explain the vector acting on the left temporal bone, (Liem, 2004).
The remaining vector that remained with a passive correction of the cranium indicated the right tentorial membrane was restricted near the right transverse sinus at the parietomastoid suture. Upon a release and listen I could feel the right temporal bone get drawn back into posterior rotation. The left temporal bone rotated anteriorly after the right temporal bone began to rotate posteriorly. The right temporal bone held the dominant vector acting on the cranium. A restriction in the right tentorial membrane was acting on the right temporal bone.
This was released by stabilising the occiput and firstly rotating the right temporal bone into more posterior rotation until a release was felt, and then rotating the right temporal bone into anterior rotation. This could have been a remnant of the restriction felt at the sphenoid and left temporal bone initially via the twist it would have created in the falx and then into the posterior attachment of the right tentorial membrane, (Liem, 2004; Surgueef 2007: Stylian, 2022).
After the treatment was finished Mrs B was re-assessed. She felt much better, and far more relaxed. During the meaningful task assessment, The left hip was the first site of impairment followed by the left SIJ, and then L5. The left hip was now anterior to the right but did not translate anterior to the acetabulum, the left SIJ unlocked at the end of the task after the left hip, and L5 rotated to the right as the SIJ unlocked. The rotation at L5 was less when compared to the initial screening. She was not fully stable but was significantly improved.
The findings in the thorax (FU1 and FU2)/cervical spine and cranium were also gone. The foot, again, pronated with the hip losing control. The arm had corrected as the shoulder girdles were neutral.
No taping was required for Mrs B post session as a connect cue was adequate for pelvic control in the task. Had Mrs B been in pain or needed to deadlift in the near future, I could have taped the hip into a posterior glide to facilitate more optimal biomechanics.
Given the left hip, left SIJ and L5 were still not full corrected in the task, I deduced there was a lack of coordination between the muscles of the pelvic floor, TrA and the sacral/lumbar fibres of deep multifidus. With time being quite short at this point in the treatment session I chose a cue for contraction of the pelvic floor to try to correct the remaining findings. A cue for a “20% lift of pelvic floor” improved the loss of control of the hip, SIJ and L5 in the meaningful task.
To try to find effective connect cues for the abdominal wall or pelvic floor I will often use a percentage of effort or score out of 10 to obtain an optimal contraction. Through experience I have found that when patients are left to their own devices they will often try “too hard” to recruit, for example, TrA. By giving the patient’s a quantifiable measure that ties in with the best visualisation cue, I have found this helps to achieve better outcomes. In Mrs B’s case, a “lift” cue for pelvic floor was enough to illicit a contraction of the lower fibres of TrA; however, Mrs B’s initial reaction was to contract too hard leading to contraction of internal oblique (IAO). When given the quantifiable measure of “20% effort”, this corrected the over recruitment of IAO. I chose this cue for the following reasons:
- I had treated a part of the pelvic floor.
- Mrs B had an intrapelvic restriction.
- Mrs B had given birth in the past.
- Cueing a pelvic floor contraction should also lead to a co-contraction of TrA.
Mrs B was then sent home with the following homework:
- Side lying thorax rotation to improve the articular glide in mid thorax.
- Practice hip hinging with a “20% pelvic floor lift” cue each time. Currently she could do 5 reps before feeling fatigued in the pelvic floor and losing control of the hip, which she would palpate as she did the hinge movement. Her goal was to be able to do 3 sets 15 reps with at least 1-2 minutes rest between sets.
- Deep box breathing (with a 4 second count in/hold/out) before bed.
A week later, on the second treatment Mrs B said she felt a lot better. She felt no tension in her jaw upon waking. She had addressed the stressful aspects of her life and no longer felt overwhelmed. The tightness in her spine was gone as was the stiffness in her mid-thorax.
Mrs B’s back pain was also gone; however, she mentioned she still did not feel “stable” or confident to load her lower back. She wasn’t convinced that it was back to normal, and the feelings of instability were still a part of her cognitive beliefs. She mentioned that she had a tightness in the back of her hip that she couldn’t stretch, and it seemed to become more noticeable when seated. It was a localised pain, that didn’t radiate down the leg.
Although she had mentioned sitting as a problem, I still chose the deadlift for the meaningful task assessment. This was carried out in a similar fashion to the first assessment i.e., unweighted.
Standing Start Screen Functional Unit 1 Findings
Pelvis: The pelvis was in left TPR and left IPT
Hips: The hips were now congruent with the left TPR
Thorax: TR8 was rotated to the left and translated right, TR7 rotated right and translated left
Unweighted Deadlift Functional Unit 1 Findings
Pelvis: During the task the pelvis remained in a left TPR with an unlocking of the left SIJ. This happened at the end of the range of the task i.e. 100%.
Hips: The left HOF moved further anterior relative to the pelvis and the right hip and did so before the SIJ unlocked i.e. at 90%.
Lumbar: L5 increased its rotation to the right with the unlocking of the left SIJ.
Thorax: TR7 & TR8 both increase their rotation and translation at the end of the range of the task i.e. at 100%.
Correcting the hip alone did not correct the pelvis or thorax. Correcting the hip and pelvis improved TR7 & TR8 and the task but Mrs B did not feel comfortable. I needed a co-correction of the left hip, pelvis for control (using the connect cue) and thorax at TR8 to correct the task. Correcting TR8 corrected TR7. This time I was able to get a full correction of TR8.
FU#1 Drivers: Co-drivers: Left hip, pelvis, thorax (TR8)
Further assessment of the left hip
Same findings as first session.
A passive mobility test done in supine at the angle of the loss of control revealed a vector that extended from the sacrotuberous ligament to the posterior side of the obturator internus tendon as it wraps around the back of the ischium and attaches to the greater trochanter. Further assessment via palpation of the vector revealed it was the sciatic nerve. It had a restriction in its mobility within the tissue. There was no lateral glide of the sciatic nerve.
Stecco (2015), says that the obturator fascia continues with obturator internus covering the superior and inferior gemelli. This fascia attaches sacrotuberous ligament and attaches over the quadratus femoris, (Stecco, 2015). This fascia is meant to provide a sliding surface for the sciatic nerve, (Stecco 2015). In the prior treatment session, I had treated the obturator internus but not this part of the membrane.
My hypothesis was that the sciatic nerve was restricted in the fascial membrane mentioned previously, which had become stiff and was preventing the normal slide of the sciatic nerve. This was likely from the chronic overuse of obturator internus.
As was noted in the screen task the left hip moved anteriorly at 90% of the task. After release of the sciatic nerve the hip no longer translated anteriorly in the task.
Further Assessment of the pelvis
The left innominate rotated posteriorly relative to the left side of the sacrum with less amplitude than the right in the open chain test of a OLS. However, it still moved freely in the movement. This indicated it was unlikely to be an articular vector acting on the left SIJ.
This test was conducted with the joint in its close packed position. I tested this before testing passive mobility. I did this test to ensure Mrs B understood that her pelvis had no ligamentous compromise.
I brought the pelvis into a symmetric position by bolstering the left leg and the left innominate was anterior. I then did a glide of the joint into the first barrier of restriction focusing on either to the superior, middle, or inferior portions of the joint. A listening from gliding the superior, middle, and inferior portions of the left SIJ posteriorly in the plane of the joint gave a medial and cephalad vector that headed towards the loops of the small intestine and the root of the mesentery. This was done by loading the SIJ passively and then releasing and listening. The middle part gave the strongest vector. The root of the mesentery is a strong piece of fascial tissue that attaches to the back body wall and supports the small intestine, (Barral, 2020). Barral notes that c-section deliveries can cause vectors of pull/adhesion in the loops of the small intestine and root of the mesentery, (Barral, 2006, Barral 2020). The visceral vector acting on the pelvis could have been from the c-section birth 17 years previously.
I confirmed the this by using a Barral listening technique over the pelvis and lower abdomen to confirm the vector. These vectors feel like soft pieces of marshmallow trapped in the pelvis with a thick tight barrier drawing them towards the spine.
The SIJ lost control at 100% of the task after release of the vectors. This was corrected with a 50% belly button to spine cue. This is described after the release below
Further Assessment of the thorax (TR8)
Increase translation/rotation during the meaningful task. This occurred after the hip and pelvis gave way in the meaningful task.
The 8th thoracic ring could be fully corrected this time. On release of the ring there was a strong visceral vector drawing the ring into left rotation and right translation. The vector drew the rib in towards the liver with an inferior pull towards the pelvis.
Due to the involvement of a visceral vector, I used a Barral listening technique on the abdomen to determine what the visceral restriction was. It was the splenic flexure of the ascending colon where it attaches to the diaphragm behind the liver. This vector feels like a like a lump resting behind a large ham. The lump has an inferior pull on it.
After release of the visceral vectors acting on the ring, the ring was stable in the task. It did not translate even with a loss of control at the pelvis.
2nd Session Treatment of the Drivers
I released the sciatic nerve first using a Barral technique that takes the hip slowly into flexion while holding the sciatic nerve in the direction of restriction. This involves waiting for the inspiration phase or expansion phase of the nervous system to move the hip, stopping in exhalation or contraction. A passive correction of the hip yielded no further vectors.
I then released the root of mesentery using a Barral technique that involves gripping either side of the membrane, drawing it anteriorly and then taking it into directions of restriction or ease until a release is felt. A passive correction of the left SIJ still gave an intrapelvic vector that with some pelvic listening turned out to be some loops of the small intestine. They were released by grasping the restricted loops and gently taking them into directions of resistance and ease until they released. A passive correction of the SIJ yielded no further vectors.
I lastly treated the thorax restriction by treating the splenic flexure of the descending colon where it attaches to the diaphragm. This was done in sitting and involves lifting the splenic flexure of the colon with the patient in thoracic flexion. Then slowly having the patient extend, stopping when tension is felt in your fingers until the patient is fully neutral in sitting again. After the release I palpated the thorax and could no longer feel the translations at TR7 & TR8. An active mobility test demonstrated optimal biomechanics.
I re-assessed Mrs B in the meaningful task. She noted that her hip felt “lighter” now and she could breathe better; however, the left SIJ was still unlocking at the end of the range i.e., 100% of the task. The thorax and hip findings were corrected. When I manually corrected the SIJ Mrs B felt better. We tried the “20% pelvic floor” lift cue we had previously used but found this was no longer effective in the task.
I now needed to do an assessment of the motor control of the pelvis. I tested the recruitment ability of transversus abdominis in supine.
Motor Control Assessment and Active control of the pelvis
In supine when cued for the “20% pelvic floor lift” I found the middle and lower portion of the left side TrA was not co-contracting. We tried a belly button to spine cue and found she
overactivated internal oblique. I cued for “50% belly button to spine” and this corrected the IAO overuse. I then tested the cue in the task. This time we found she could control the left SIJ effectively in the task with this connect cue.
Mrs B’s connect cue was “50% belly button to spine” during the task practice.
Mrs B was then sent home with homework to work on regaining control of the left SIJ while practicing the meaningful task. She could do 8 repetitions before she lost control of the left SIJ. Her goal was to reach 3 lots of 15 repetitions to improve the strength endurance of TrA in the task. We spent time ensuring she understood what it felt like when she wasn’t using an effective strategy. Her hip no longer translated, so she needed to understand what it felt like to have control versus losing control. This helped to allay the fears of her spine simply being “unstable”. She now felt like she had control of the issue.
The next treatment session yielded no suboptimal alignment, biomechanics or control or any body region during the meaningful task assessment in an unweighted deadlift. So, we added weight and noted she just felt weak. She could control the movement from a stability perspective. She just lacked confidence and had lost some conditioning. From this point, the treatment sessions focused on improving strength and control of the hip, lumbar spine, and abdominal wall in a progressive overload manner until she felt confident to load her spine. Now she was stable, she was keen to address anything that might be weak and would prevent her from making progress in the future.
In the next few sessions as squatting and general barbell/pull up bar loading were part of the movements she would encounter in CrossFit we also assessed these and found the foot ended up being a driver in a squat task. The hand grip on the left side needed to be strengthened too. These tasks were tested with weight after Mrs B had done some strength work in the gym again.
With this progressive overload program, and homework to fix the various weakness that developed from the years of compensating, Mrs B returned to CrossFit classes around 3 months after her initial injury. Since then, she has reported that she has felt none of her old issues and feels more confident to lift without fear of injury.
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Clinical Mentorship in the Integrated Systems Model
Join Diane, and her team of highly skilled assistants, on this mentorship journey and immerse yourself in a series of education opportunities that will improve your clinical efficacy for treating the whole person using the updated Integrated Systems Model.
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