Learning Objectives• Recognize the high prevalence of LBP costly effects to the US

economy• Identify areas of regional interdependence in patients presenting with

LBP or other neuromusculoskeletal concerns

Initial Presentation• CC:

• F/U Bilateral LBP• HPI:

• 49 y/o Caucasian F• PMH of asymptomatic L4-L5 disc herniation x20 years prior• Recent Trauma: 8 days ago she slipped off stairs and fell on her R

buttock• Pain is dull/achy, constant, and 5/10 severity• Current therapy: Chiropractic care, worsened pain• Slightly alleviated with ibuprofen• Denies numbness, tingling, or weakness

• Osteopathic Structural Exam

Conclusions• Must remember the First Tenet of Osteopathy “The body is a unit”• These results provide evidence for the practical utility of understanding

the myofascial meridians in the context of OMT and LBP• Follow-up to address:

• effectiveness of home exercise program • long-term effects of treatment on LBP

References & Acknowledgements1. Deyo RA, Tsui-Wu YJ. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine (Phila Pa

1976). 1987 Apr;12(3):264-8.2. Cassidy JD, Carroll LJ, Côté P. The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability

in Saskatchewan adults. Spine (Phila Pa 1976). 1998;23(17):1860. 3. Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences [review]. J Bone Joint Surg Am.

2006;88(suppl 2): 21-24.4. Weishaupt D, Zanetti M, Hodler J, Boos N. MR imaging of the lumbar spine: prevalence of intervertebral disk extrusion and

sequestration, nerve root compression, end plate abnormalities, and osteoarthritis of the facet joints in asymptomatic volunteers. Radiology. 1998;209(3):661.

5. Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2007;37(11):658-660.

6. Myers, T. (2009). Anatomy trains : myofascial meridians for manual and movement therapists. 2nd ed. Oxford [etc.]: Elsevier Health Sciences.

7. Bandy WD, Irion JM, Briggler M; The Effect of Time and Frequency of Static Stretching on Flexibility of the Hamstring Muscles, Physical Therapy, Volume 77, Issue 10, 1 October 1997, Pages 1090–1096

Special thanks to Dr. Sandhouse, Dr. Boesler, and Dr. Qureshi for their continued support and mentorship throughout the year

Introduction• Low Back Pain (LBP)

• 84% of adults have back pain at some point in their lives (1,2)• Total cost of LBP in the US was estimated to exceed $100 BILLION

per year (3)• Correlation of LBP Sx to imaging findings is difficult• Disc herniations are seen in 22-67% of asymptomatic adults on

incidental MRI (4)• Regional Interdependence (RI)

• Concept that “seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint” (5)

• The First Tenet of Osteopathic Medicine• “The body is a unit”

• Myofascial Meridians• Biomechanical concept that consecutive muscles and the associated

webs of fascia in the body create “lines of pull… which transmit strain and movement through the body’s myofascia around the skeleton” (6)

L2 ERRSR Muscle Energy ImprovedQL hypertonic B/L (R>L) Direct Myofascial Release ImprovedPiriformis hypertonic B/L Muscle Energy ImprovedR psoas TP Counterstrain improved

Regional Interdependence of Myofascial Meridians in Chronic Low Back Pain Nicholas R. Wawrzyniak, OMS-III, MS1; Gabriela Teixeira, OMS-III1; Mark Sandhouse, DO, MS1

1Nova Southeastern University Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, FL

Outcomes• Ankle dorsiflexion after treatment: L = +10°

• 20* improvement• Pt reported reduction of symptoms after treatment, including no pain

while standing barefoot

• Sept. 5, 2018• Pain 2/10 exacerbated by standing & long walking & alleviated by

foam rolling and rotational stretches• Oct. 10, 2018

• LBP has been worse recently, an “aching tightness,” 0/10 seated, 4/10 standing. Pain worse while wearing flat shoes, standing and slow walking; alleviated by sitting & wearing high heels

• Pt was unable to achieve 0 degrees of dorsiflexion (stuck in plantarflexion)

• Dec. 5, 2018• Pain described as a “tightness” 2/10 currently, at its worst 7-8/10 . Pt

has been stretching calves 5 days/week since last visit; however, Pthas only been holding stretches for 5 seconds each day7. Pt began seeing physical therapist x1-2 weeks, who believe the hips and psoas are key lesions.

• Negative Thomas test & prone instability test• Dorsiflexion: L ankle = -10°; R ankle = +10°

Figures 3.1 & 3.3 – Myers, TW. Anatomy Trains. 2009 7

Treatment Progression

HypothesisApplying the models of Regional Interdependence and the

Superficial Back Line of myofascial meridians to our case, the relief of pain with wearing high heels (plantarflexion) suggests

the pain may be exacerbated by a restriction and/or hypertonicity in the calves

Superficial Back Line