Treatment Sequencing Guidelines

Treatment Sequencing Overview

• Treatment sequencing orders the evaluation and treatment of somatic dysfunctions during a clinical visit.
• Proper sequencing enhances treatment effectiveness, efficiency, and patient comfort.
• Incorrect sequencing may lead to minimal improvement or recurrence of dysfunction.
• Sequencing guidelines are not absolute and can be adapted with experience.

Rapid-Fire Treatment Sequencing Guidelines

• Treat vertebra before ribs.
• Prioritize innominate shears over sacral dysfunctions.
• Address structural rib dysfunctions before respiratory rib dysfunctions.
• Treat the most tender point first.
• Address pubic shears before single dysfunctions.
• Treat L2 and psoas central tender points before peripheral tender points.
• Treat L5 dysfunction before sacral torsion.
• Prioritize non-physiologic dysfunctions over physiologic dysfunctions.

Clinical Application Examples

• For T4 flexed/rotated dysfunction and rib exhalation dysfunction, treat the vertebra first.
• For lateral rib compression and rib exhalation dysfunction, treat the compressed rib first (addressing a structural issue).
• When multiple tender points are present, treat the one in the middle first.
• In L5 FRS and sacral torsion scenarios, treat L5 first.
• For sacral extension and pubic shear, treat the pubic shear first.
• When a patient presents with the following tender point sensitivities; most, moderate and least, treat the most tender first.
• In a case with innominate shear and sacral torsion, treat the innominate shear first.
• Either L2 dysfunction or psoas tender points can be treated first in psoas syndrome, but both must be addressed
• In cases of midline sacral pain, treat posterior sacral torsion before innominate rotation

Physiologic vs. Non-Physiologic Dysfunctions

• Respiratory rib dysfunction involves ribs stuck in inhalation or exhalation.
• Structural rib dysfunction involves ribs displaced forward or backward.
• Type I mechanics are group curves and are considered relatively functional..
• Type II mechanics is when a single segment sidebends and rotates to the same side.
• Anterior sacral torsion is a physiological movement, posterior sacral torsion is not.
• Non-physiologic dysfunctions are more problematic than physiologic ones.

Sacral Torsions

Posterior Sacral Torsions

• A deviation from normal, healthy sacral mechanics.
• Often caused by restrictions or abnormal movement patterns.
• Do not occur during typical motion.

Innominate Rotations

• Part of the normal range of motion during functional activities like walking.
• Expected to occur in response to normal movement and gait.

Example Treatment Sequences

• For low back pain, address innominate and pubic shears early, then lumbar dysfunction and psoas hypertonicity before sacral dysfunction.
• For shoulder pain, treat spinal and rib cage dysfunctions first.

Treating Atypical Anatomy

• In patients with structural scoliosis, focus on motion testing, barrier end-feel, and tissue texture abnormalities instead of static asymmetry.
• Evaluate group curve bases and transition zones.

Additional Sequencing Practices

• Treat the area of greatest restriction first.
• Treat within the patient's compensation pattern, following Gordon Zink’s model focusing on transition zones.
• Coordinate all diaphragms from plantar fascia to tentorium cerebelli.
• Other approaches involve starting treatment from the top or bottom.

Identifying Root Causes

• Be aware that the location of a dysfunction may not always be the locality of the pain.
• Utilize a full-body screening, such as the Stiles screen, to identify less apparent dysfunctions.

Compensation Patterns

• Compensatory patterns are interconnected
• Compensation mechanisms, while sometimes helpful, can lead to further imbalances.
• Models like Gordon Zink’s help systematically sequence treatment to correct primary dysfunctions and resolve compensatory changes.

Sphenobasilar Synchondrosis (SBS) Overview

• The Sphenobasilar synchondrosis (SBS) is a cartilaginous joint between the sphenoid and occipital bones at the base of the skull.
• The sphenobasilar synchondrosis plays a crucial role in the craniosacral rhythm.
• There are two categories of cranial motion dysfunctions that affect the SBS

Sphenobasilar Synchondrosis Dysfunction (Mechanical Patterns)

• These terms describe the types of mechanical patterns in which the sphenoid and occipital bones move under abnormal conditions.
• These involve the directional movement and positioning of the bones at the SBS.
  • Compression:
    • The sphenoid and occiput are pressed together with restricted motion
    • May cause discomfort, headaches, and other symptoms related to craniosacral dysfunction.
  • Lateral Strain:
    • The sphenoid and occipital bones move in opposite directions horizontally.
    • Can cause a strain across the SBS.
    • These patterns typically cause the head to become twisted
    • Vertical Strain:
      • Abnormal movement along the vertical axis, either compressing or separating the sphenoid and occiput.
      • This strain often leads to a distorted head shape or can be associated with certain types of postural issues.

Sphenobasilar Synchondrosis Dysfunction (Physiologic Movements)

• These terms describe the physiologic movements of the SBS in relation to the cranial bones.
  • Torsion:
    • Refers to a rotational movement of the sphenoid and occiput around a vertical axis.
    • When this motion is altered or restricted, it creates a cranial torsion dysfunction, often causing headaches or tension in the cranial region.
    • Is typically named for the direction of the sphenoid bone's movement (e.g., left torsion or right torsion).
  • Flexion/Extension:
    • The SBS moves through a flexion-extension motion with the craniosacral rhythm.
    • Dysfunction in this pattern can lead to tightness, tension, or a feeling of fullness in the head.
  • Sidebending Rotation:
    • Describes a combined motion where the sphenoid and occiput rotate around the vertical axis while also sidebending in a lateral direction.
      • Dysfunction in this motion could manifest as tension on one side of the skull or neck, leading to headaches and discomfort along the side of the head or neck.

Key Difference:

• Compression, Lateral Strain and Vertical Strain, refer to abnormal or dysfunctional patterns of movement that disrupt normal cranial motion.
• Torsion, Flexion/Extension and Sidebending Rotation: refers to the physiological and normal movements that the SBS undergoes, which can become dysfunctional under certain conditions.