The only personnel needed is the physician.

Communication is very important, both when performing the exam and treating the patient. The physician should describe to the patient the procedure and clinical reasoning behind the treatment as well as the risks, benefits, and alternatives. Consent needs to be obtained prior to treatment. The physician then performs an osteopathic structural exam, taking note of somatic dysfunctions and areas of greatest restriction.

SI BLT- Short Lever

The patient is lying supine on the table. Diagnose the side of restriction with the ASIS compression test. Sit facing the patient on the side of the SI restriction. Contact under the pelvis at the SI joint with the cephalad hand, so the finger pads are on the medial aspect of the SI joint and place the caudad hand on the ipsilateral ASIS. Bring the innominate through a range of motion, including superior/inferior shear, anterior/posterior rotation, and inflare/outflare. When using indirect BLT, bring the innominate into its position of ease in all the motions tested and fine-tune until a point of balanced tension between physiologic neutral and the direct articular barrier is reached. Make sure that the ligaments still feel engaged. The same is true when using direct BLT, except the innominate is brought into its restriction in all the motions tested. Anterior pressure may need to be applied to the sacrum with the hand under the SI joint, which will facilitate the release by decompressing the SI joint.

Once the point of balanced tension is found, hold this position until softening under the hand that is contacting the SI joint is felt. Warmth increased motion, or a sensation that less force is needed to hold the joint in its treatment position might also be felt. Once this happens, subtle motions can be used to find the next point of balanced tension. Repeat this process until no further change is appreciated. Reassess with the ASIS compression test. It should be noted that not all schools teach direct and indirect BLT. Those that do not may instead focus on finding a point of balanced tension without specifying whether this was achieved by first going into the direction of ease or restriction.

SI BLT- Long Lever

The patient is lying supine on the table. Diagnose the side of restriction with the ASIS compression test. Stand on the side of the SI restriction facing the patient’s head. Contact the SI joint with the hand that is away from the patient, which will be used to monitor for changes. Use the arm closest to the patient to hold the ipsilateral leg and use it as a long lever to create balanced tension at the SI joint. Internally rotate the femur in the acetabulum to engage the SI joint. Bring the leg into abduction/adduction, flexion/extension, and distraction/compression into the SI joint, noticing which motions soften and create tension at the SI joint. Stack all of the motions that create ease at the SI joint if indirect BLT is being used or all of the motions that create tension if direct BLT is being used, and fine-tune to a point of balanced tension.

Once the point of balanced tension is found to hold this position until softening under the hand that is contacting the SI joint is felt. Warmth increased motion, or a sensation that less force is needed to hold the joint in its treatment position might also be felt. Once this happens, subtle motions can be used to find the next point of balanced tension. Repeat this process until no further change is appreciated. Reassess with the ASIS compression test.

SI Decompression, direct- Supine

This technique is applicable in the treatment of SI compression and is performed in a direct manner. Diagnose the side of restriction with the ASIS compression test. With the patient lying supine and the provider seated at the side of SI restriction, the provider contacts the sacrum with the caudad hand, fingers pointing cephalad (typically by positioning the hand between the patient’s legs) in order to provide stability to the sacrum.  Following this, the provider’s cephalad hand applies lateral traction to the PSIS on the affected side until a release of the joint is felt. An optional respiratory component may be included in this technique by having the patient inhale and exhale deeply while palpating for motion at the SI joint space and using this respiratory cooperation to encourage the release and balance of the affected ligaments.

A release may be felt as a slight pull of the innominate as the ligaments balance at the SI joint. Often an increase in warmth, softening of the surrounding tissues, and/or an improvement in sacral motion with either primary or secondary respiration may be noticed. An increase in motion at the SI joint is observed upon retest as an increase in mobility with the ASIS compression test.

LS Decompression- Prone

The patient is lying prone on the table. Stand on either side of the patient and face the table. Contact the sacrum with the cephalad hand, so the heel of the hand is at the sacral base. Be mindful that the fingertips are not contacting sensitive areas. Cross the other arm over and contact the lower lumbar segments with the caudad hand. Position the caudad hand perpendicular to the cephalad hand, so the hands form the letter “T,” or contact the lower lumbar segments with the palm of the caudad hand, so the fingertips point superiorly. To assess for restriction, have the patient take deep breaths and notice the motion of the sacrum and lumbar spine at the LS junction. With an inhalation, the sacrum should go into counternutation, and the lumbar lordosis should flatten. With an exhalation, the sacrum should go into nutation, and the lumbar lordosis should increase. To treat, keep the arms fairly straight with a slight bend at the elbows, and lean over the patient. The hands will naturally separate from each other and create a distraction at the LS junction. Notice the amount of restriction at the LS junction when distraction is applied at the joint, so the initial finding can be compared to the reassessment at the end. Then induce rotation of the sacrum on the lumbar spine and rotation of the lumbar spine on the sacrum until you find a point of balanced tension. Warmth, softening, increased motion, or a sensation that less force is needed to hold the joint in its treatment position might also be felt. Once this happens, subtle motions can be used to find the next point of balanced tension. Repeat this process until no further change is appreciated. Reassess by repeating your diagnostic assessment. 

LS Decompression- Supine

The patient is lying supine on the table. Sit on either side of the patient-facing the patient’s head. Contact the lower lumbar region with the cephalad hand, so the finger pads are on the contralateral paraspinal muscles, and the thenar/hypothenar eminences are on the ipsilateral paraspinal muscles. Have the patient bend one or both knees and lift their pelvis off the table. Position the arm closest to the patient in-between the patient’s legs and contact the sacrum, so the fingertips are at the sacral base, and the hands are perpendicular to each other. Have the patient relax their pelvis back down on the table. They can either keep their knees bent or straighten them out. Keeping the hand and wrist relaxed will help with palpation of the tissues while it is under the weight of the patient and improve provider ergonomics. To assess the motion of the sacrum on the ilia, induce nutation/counternutation on its transverse axes by flexing and extending the wrist and right/left rotation on its vertical axes by pronating and supinating the wrist of the hand that is under the sacrum.

To assess the motion of the sacrum with respect to the lumbar spine, induce lumbar rotation by flexing and extending the wrist of the hand that is under the lumbar spine. Assess the motion at the LS junction when the patient takes deep breaths. With an inhalation, the sacrum should go into counternutation, and the lumbar lordosis should flatten. With an exhalation, the sacrum should go into nutation, and the lumbar lordosis should increase. Assess whether adding compression or distraction to the LS junction creates more freedom of motion there. To add compression bring the caudad hand superiorly and the cephalad hand inferiorly. To add distraction, bring the caudad hand inferiorly and the cephalad hand superiorly. To treat, add compression or distraction, induce motion in all the planes tested in the sacrum, and add a rotation of the lumbar spine. Depending on whether direct or indirect BLT is used, the provider will first go into the direction of ease or restriction and then fine-tune to a point of balanced tension. Warmth, softening, increased motion, or a sensation that less force is needed to hold the joint in its treatment position might also be felt. Once this happens, subtle motions can be used to find the next point of balanced tension. Repeat this process until no further change is appreciated. Reassess by repeating your diagnostic assessment.

While BLT is one of the safest techniques, patients may still experience soreness for several days following treatment and are advised to drink plenty of water after the treatment to prevent or minimize soreness.

The philosophy of osteopathic medicine is to treat the patient as a whole. The answer to the question of when OMT should be used on the pelvis can be addressed when somatic dysfunction is found on an osteopathic structural exam and when treatment would benefit the patient. While BLT is one of many osteopathic treatment modalities, the decision to use one modality over another comes down to provider preference and the responsiveness of the patient’s tissues. Here are a couple of specific examples of how OMT for pelvic dysfunction can be applied. 

The pregnant patient: There are many physiologic and biomechanical changes that happen to the body during pregnancy. These changes can lead to symptoms, including back pain, pelvic pain, stiffness, and lower extremity edema that have a large impact on a person’s ability to function in daily life. Many medications normally prescribed to address these symptoms are not recommended during pregnancy, and osteopathic manipulative treatment is a nonpharmacologic option for pregnant patients looking for relief. In the Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects (PROMOTE) study, there was not a higher conversion rate to high-risk status in third-trimester patients in the OMT group indicating that OMT is safe for this patient population. In addition to the pelvic region (pelvic diaphragm, innominate, and sacrum), attention should also be given to the occipitoatlantal joint, cervical vertebrae, clavicles, and Sibson fascia, thoracoabdominal diaphragm, ribs, hips, and cranium during the assessment and treatment with OMT in the pregnant patient.[6] 

The hospitalized patient: BLT is a useful modality in treating the hospitalized patient because active participation of the patient in the treatment is not required, and it can be adapted to use in any part of the body while the patient is supine. The Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) randomized controlled trial showed shortened length-of-stay and decreased in-hospital mortality rates in certain subgroups, which supports the role of OMT as an adjunctive treatment to standard of care in patients hospitalized with pneumonia.[7]

Another study looking at the effects of OMT on hospital length-of-stay and incidence of postoperative ileus in general surgical patients showed that OMT decreased time to flatus and decreased length-of-stay.[8] The anatomy that is targeted with OMT in the pelvis can be thought of in terms of autonomics, biomechanics, and circulation. Autonomic tone can be modulated through manipulation of the sacrum. The pelvic splanchnic nerves arise from S2-S4 nerve roots and carry afferent parasympathetic nerve fibers to the distal end of the transverse colon, descending colon, sigmoid colon, rectum, cervix, and upper vagina.[9] 

Targeting the parasympathetic fibers innervating the colon could be useful in the postsurgical patient in trying to encourage the return of normal bowel function. Treating dysfunction at the lumbosacral junction and the sacroiliac joints could restore mobility and help in the process of getting the patient out of bed and walking again. Treatment of restriction in the pelvic diaphragm, which is recognized as a muscle of respiration, opens up the pathway for lymphatic and venous return and decreases any congestion in the area. A goal in treating a hospitalized patient with OMT is to help decrease the patient’s allostatic load by correcting somatic dysfunction so that they put more of their body’s energy towards healing.

The effectiveness of BLT primarily stems from an in-tune palpatory sense on the part of the provider. Since this is developed through hands-on practice, it is important that as a provider, one continues to hone these skills through repetition, as this will result in the highest likelihood of correctly diagnosing and treating patients with this particular modality. Practitioners are encouraged to attend workshops and meetings where they can further develop not only their palpatory skills with BLT but also many other treatment modalities within osteopathic manipulative medicine. Proper application of this technique can be very beneficial to nearly all patients as it is a gentle and very tolerable approach for even the most vulnerable patient populations. Further research into the efficacy of BLT in the treatment of ligamentous somatic dysfunctions could shed light on novel uses for this effective modality in the field of osteopathic manipulative treatment.