Reflections on a Recent Case: Connecting the Pelvis and Upper Cervical Spine Sacrum and Sternum
I had a wonderful opportunity to spend a day with a Physical Therapist Deena Goodman from Los Angeles, CA. She is learning my work via distance learning, which I am just developing and it is not yet ready for prime time. It was fortunate that she was coming to Las Vegas to visit some friends. Here is a link to her web site www.goodmanphysicaltherapy.com. I will ask her to provide some feedback to post at the bottom.
In demonstrating the spring tests on her, I came to realize that she lacked passive side glide of the pelvis moving from the left to the right. I test this movement in supine and do so because there are cases which are too subtle to be observed with gait and standing posture. This is not a sacroiliac motion dysfunction, but rather a motion dysfunction of the entire pelvis; the pelvis as a unit. Given her motion restriction, I predicted (based on experience) that she would have an upper cervical restriction as a compensation and she affirmed that she was aware of it every time she performed a Gyrotonic exercise which she demonstrated. This Gyrotonics exercise involves a combined movement of cervical right rotation with thoracic and lumbar spine rotation, maximizing end range spinal motion to the right.
Passive testing revealed these motion restrictions (Grade 2-):
I explained that this was a reflex phenomenon and that most likely it would resolve in response to correcting the pelvic side-glide restriction. I had her lie on the left side with 3 pillows underneath the left side of her pelvis for 5 minutes. Retesting revealed that side-glide of the pelvis was restored and immediate retesting of the upper cervical spine revealed that all the previous restrictions motions were normal. She then demonstrated an ability to perform the exercise that usually provokes her of the cervical restriction; now done with ease. This highlights why I never treat the upper cervical spine first, instead I make sure that there is no postural/movement dysfunction below that is contributing to an upper cervical compensation. Since the body responds in this manner, it would be ideal if published case studies mentioned the proximal/distal compensation, and reevaluated it after treating the primary dysfunction, to assure that it did in fact resolve. There are in fact times in which the distal compensation does require a seperate, specific treatment.
Mild soreness and mild tightness in the right trochanteric region told us there might be more work to be done. Palpation in prone and supine revealed increased soft tissue tone over the right pubic bone and over the right lower quadrant of the sacrum, and just below. I predicted that there might be a sacroiliac motion dysfunction, and if so; it may announce itself at end range flexion (Muslim Prayer Position). It did, she had a sacral torsion about an oblique axis. I will avoid the traditional nomenclature which many find to be confusing. I will describe it in terms of position, movement restriction, and treatment.
Prior to treating the sacrum I explained that sacral movement dysfunction often has a corresponding restriction at the sternum. I think that came from the book Osteopathic Lesions of the Sacrum by Richards. Bill Brooks, DO and his colleagues have published research on sternal mobility. Spring testing of the anterior chest wall revealed a very distinct motion block of A-P spring at the right lower sternum, extending to the costochondral segments. It was not subtle. This sternal motion block resolved immediately in response to treating the sacrum. Deena reported that she was then able to inspire more fully and more freely.
I also treated the L5-S1 motion segment, the thoraco-lumbar junction, and taught self treatment. She reported that the trochanteric soreness and tightness was resolved. She retained a Type 1 (Osteopathic terminology) pattern of lumbar spine in flexion, which did not respond readily, and additional attention may be fruitful.
I think there are several salient points in this very brief case.
October 9, 2007
Hi Jerry,
Post treatment by you: I felt sore in my upper cervical spine, especially right side if my memory serves me right! My body continues to feel "light" in my pelvis (yeah!) and no complaints of cervical "tension" or pain so to speak. Lots of crackling in the joints (right side only? vs. more on the right-haven't payed attention to this) with C/S forward bend and side bend motions to stretch my neck. I will try out the Gyro movement tomorrow and let you know if the cervical sx's are gone!!!!!
Deena Goodman, PT
In demonstrating the spring tests on her, I came to realize that she lacked passive side glide of the pelvis moving from the left to the right. I test this movement in supine and do so because there are cases which are too subtle to be observed with gait and standing posture. This is not a sacroiliac motion dysfunction, but rather a motion dysfunction of the entire pelvis; the pelvis as a unit. Given her motion restriction, I predicted (based on experience) that she would have an upper cervical restriction as a compensation and she affirmed that she was aware of it every time she performed a Gyrotonic exercise which she demonstrated. This Gyrotonics exercise involves a combined movement of cervical right rotation with thoracic and lumbar spine rotation, maximizing end range spinal motion to the right.
Passive testing revealed these motion restrictions (Grade 2-):
- blocked left side-glide of C1 (first cervical vertebrae)
- reduced left rotation of C1
- blocked right rotation of occiput on C1
- blocked left side-bending of occiput
- blocked right side-glide of occiput
I explained that this was a reflex phenomenon and that most likely it would resolve in response to correcting the pelvic side-glide restriction. I had her lie on the left side with 3 pillows underneath the left side of her pelvis for 5 minutes. Retesting revealed that side-glide of the pelvis was restored and immediate retesting of the upper cervical spine revealed that all the previous restrictions motions were normal. She then demonstrated an ability to perform the exercise that usually provokes her of the cervical restriction; now done with ease. This highlights why I never treat the upper cervical spine first, instead I make sure that there is no postural/movement dysfunction below that is contributing to an upper cervical compensation. Since the body responds in this manner, it would be ideal if published case studies mentioned the proximal/distal compensation, and reevaluated it after treating the primary dysfunction, to assure that it did in fact resolve. There are in fact times in which the distal compensation does require a seperate, specific treatment.
Mild soreness and mild tightness in the right trochanteric region told us there might be more work to be done. Palpation in prone and supine revealed increased soft tissue tone over the right pubic bone and over the right lower quadrant of the sacrum, and just below. I predicted that there might be a sacroiliac motion dysfunction, and if so; it may announce itself at end range flexion (Muslim Prayer Position). It did, she had a sacral torsion about an oblique axis. I will avoid the traditional nomenclature which many find to be confusing. I will describe it in terms of position, movement restriction, and treatment.
- right lower sacral quadrant prominent (posterior)
- right lower sacral quadrant blocked to P-A spring
- left sacral ILA inferior
- left sacral ILA lacked superior spring
Prior to treating the sacrum I explained that sacral movement dysfunction often has a corresponding restriction at the sternum. I think that came from the book Osteopathic Lesions of the Sacrum by Richards. Bill Brooks, DO and his colleagues have published research on sternal mobility. Spring testing of the anterior chest wall revealed a very distinct motion block of A-P spring at the right lower sternum, extending to the costochondral segments. It was not subtle. This sternal motion block resolved immediately in response to treating the sacrum. Deena reported that she was then able to inspire more fully and more freely.
I also treated the L5-S1 motion segment, the thoraco-lumbar junction, and taught self treatment. She reported that the trochanteric soreness and tightness was resolved. She retained a Type 1 (Osteopathic terminology) pattern of lumbar spine in flexion, which did not respond readily, and additional attention may be fruitful.
I think there are several salient points in this very brief case.
- Physical Therapist need to get worked on from time to time!
- Beyond the SIJ paradigm, the pelvis (as an entire structure) needs to evaluated as a distinct structure that has its own set of biomechanical function and dysfunction.
- Palpation of pelvic soft tissue will sometimes indicate that a subtle movement dysfunction is present, yet needs to be evaluated in another position, such as Muslim Prayer Position, at which point it will no longer be subtle.
- Pelvic side-glide restriction (and other pelvic/SIJ patterns) causes a reflex muscular compensatory pattern in the upper cervical spine, which reduces passive accessory motion.
- Sometimes the distal compensation will not resolve until the cause is isolated and treated. In the above example an upper cervical restriction spontaneously resolved when the pelvic motion restriction was resolved.
- It is often appropriate to screen the entire body.
- Sacral motion dysfunction often induces a restriction in the sternum and costochondral area with reduced inhiliation.
- There is an alternate way of describing sacral torsions about a vertical axis, which for many (based on course feedback) it is less confusing than nomenclature such as "Right on Left" sacral torsion.
October 9, 2007
Hi Jerry,
Post treatment by you: I felt sore in my upper cervical spine, especially right side if my memory serves me right! My body continues to feel "light" in my pelvis (yeah!) and no complaints of cervical "tension" or pain so to speak. Lots of crackling in the joints (right side only? vs. more on the right-haven't payed attention to this) with C/S forward bend and side bend motions to stretch my neck. I will try out the Gyro movement tomorrow and let you know if the cervical sx's are gone!!!!!
Deena Goodman, PT
