We are very fortunate and excited to have Dr. Saj Servey with us. He's a professor at the UNTHSC Texas College of Osteopathic Medicine. He holds board certifications in both PM&R and osteopathic neuromuscular medicine, or NMM, where certificates of added qualification in pain medicine and medical acupuncture. Dr. Servey is an award-winning educator and has lectured extensively at the local, regional, national, and international levels on topics including osteopathic manipulative medicine, performing arts medicine, and medical acupuncture, as well as pain management. So please join me in welcoming Dr. Servey. Okay, good morning. How's everyone doing? We're all right? All right. Can we get the... Yep, perfect. Yep, so that's that. So, you know, we're here to... You know, I commend you, you know, eight in the morning on a Saturday that you're here and conscious and caffeinating, appropriately so. So we're here to talk about, you know, OMM and back pain and wanted the click-baity title, you know, to try to get you in here. So, you know, my intention was that, you know, I wanted to set up some parameters for how we're going to do this. So my parameters were three moves or less and minimal diagnostic consideration, right? And able to address the majority of sort of idiopathic musculoskeletal back pain that you're going to see, you know, sort of like the common garden variety back pain that you're going to see coming into your office. So that was... Those were my three criteria. I think we've accomplished it. But as we say, you know, you don't learn OMM... You don't get better at OMM by reading OMM and you don't get better at OMM by watching OMM and you don't get better at OMM by listening to OMM. You get better at OMM by doing OMM. So we have some tables here and around the room. So I definitely encourage you to find one, partner up with somebody. We've got plenty of space. We're going to go through a couple techniques. I'm going to borrow somebody and demonstrate those things and then we'll give you some time to work on those things and I'll walk around the room and coach you through it if you need help with any of the specifics of those things. And we should finish with plenty of time. So if we have questions or if there's any folks in the room who are a bit more advanced in their OMM skills and want to have a sort of higher level discussion about technique or other things that we could do or accomplish, we can certainly do that, time permitting. So there's the learning objectives for today. I don't have any disclosures for this talk, but I do have a shameless plug. So I am the program director for the Performing Arts Medicine Fellowship at TCOM. So we're looking for graduating residents who are interested in learning more about OMM and performing artists and taking care of that population. So hook me up or if you, any of the attendings in the room, if you're involved with residency care and have residents or you know a resident who's going to be graduating and might be interested in spending a year with us, we would love to have you here and come join us for a year. So please ask about our Performing Arts Medicine Fellowship. We would love to learn more about it. So we all know and love the standard Thomas test. We all know this one, right? This is like first year medical school curriculum, right? They pull their knee up to their chest and if the knee comes off the table, then that means that they've got a tight psoas on that side. And so that's all well and good and it's an excellent test for a specific condition, right? Psoas syndrome. So they have a tight muscle on a side. But we can do so much more. We can do so much more with this maneuver. So obviously there's our psoas in case we forgot. And so what we're going to do is we're going to move the patient to the end of the table and we're going to repeat this maneuver and we're going to do it in a slightly different way, which is a modified Thomas test. And full disclosure, this technique was shown to me by one of my mentors, Dr. Richard Bacharach, who is in New York City. So I just wanted to give credit where credit's due. I'm not sure he actually invented this technique, but he's the one who showed it to me. So I have to sort of respect the lineage and put that disclaimer out there. And so this is the modified Thomas test. And by moving it to the end of the table, this affords us a few things. Well, first of all, that's how we do it, right? And we'll demonstrate that in a moment. And so why? What do we get by putting the person at the edge of the table as opposed to in the middle of the table? First of all, it helps us to prevent anterior pelvic tilt, which can throw off this particular measure. So by having the patient pull the knee towards their chest, it posteriorly rotates the pelvis and sort of pins the pelvis to the table. So it helps to minimize. It's not going to be perfect, but it's going to at least minimize any inherent anterior pelvic tilt that the patient may have. But also then, it allows us to assess all these other muscles, hamstring, psoas, quads, adductors, glutes too, sort of indirectly, TFL and ITP, and piriformis. So all of these muscles we can address simultaneously through this modified Thomas test. So yeah, those are those. Yep. Okay. And so once we look at all these muscles, then we can treat any or all of these muscles, either through muscle energy or through counter strain or whatever your flavor of treatment is that you like, you just do that. And we'll show you different versions for all of those things. But yeah, so I like this modification to the Thomas test because I feel that a lot of low back pain comes from the lower extremity, muscle imbalance in the lower extremity, whether that's tight hamstrings or other tight quads or other problems that patients may have. So normalizing out muscle tone in the lower limb just by itself will probably handle a significant chunk of sort of garden variety low back pain, right? So just this one by itself, if we had to pick one of our three, this is probably the one I would pick because this is going to handle a decent chunk of the back pain that you're going to see in your sort of typical musculoskeletal practice. Okay. Do we want to do it? Can we borrow somebody? Any brave soul want to be a volunteer? Jenny. Oh, okay. Sweet. Let's see. What gentleman in the back, which table is the best? Would you want this one here? The red one? All right, red it is. Okay. So I'll show it. And then if we want to break out to the tables and try it, please do. So that's really what this session is about, you trying these things. So what I want you to do is sit like you're practically falling off the table, like as close to the edge as possible. And then what I want you to do is roll back onto the table and kind of bring your knees to your chest like you're curling into a ball like that. Perfect. Good. We got her. Okay. So we got her by curling her knees into a ball. She's rotating her pelvis back so that it's pinning itself to the table. Right? And then we're going to assess one limb at a time for this particular maneuver. So I'll take her right leg. So what I'm going to have you do is just move this arm and kind of hug just that limb to the table. Right? So right from here, what we can do is we've practically got her here to assess her hamstrings. Right? So we've got her at 90. And so we can start by just extending. Oh boy. Okay. So we can start by extending her leg and checking out her hamstrings right here. Right? And seeing. And so as we know, you know, you should be kind of at, you should be able to get pretty much to zero in terms of your knee extension. She's got about, I don't know, 10, 15 degree lag on this. So she's got a little bit of tightness. Not terrible. I've definitely seen worse. And so, you know, our goal is to get from here to here. Right? And so from this position, you know, we can do a couple of things. So we're already at the sort of restrictive barrier. Right? So if we're here, we can just have her push. So go ahead and bend your knee for me. We can have her push into my hand and turn this into a muscle energy and stretch her through that. Right? If you wanted to just take this and press into these tender points here and shorten this up and do it more of a sort of indirect counter strain type of model, you could do that too. Right? If you wanted to just work this from a soft tissue standpoint, we could do that too. Right? So whatever flavor of treatment you like, you can accommodate it from this particular position. But this is a way that we can address these hamstrings. Once we've done that and we've sort of gotten her closer to where we want her, we can keep this positioning. And now what we're going to do is we're going to drop this leg off the table like so. And that's again why we have her sort of way on the edge of the table. And the view is not the greatest, but I can describe what we're looking at here. So from this positioning, we can see a lot of things. Okay? First of all, just as a Thomas test, right? If her leg comes down and she keeps the hip flexed, right? Then we can see that she's got tight psoas. Right? Also, what I noticed here probably more than anything is her quads are pretty tight. So when the leg comes off the table, the knee should just flop to 90, like basically perpendicular to the floor. Her leg is sticking out like that. So she's got tight quads. They're pulling the knee out into extension. So from here, I could hook her leg and just kind of stretch her that way and have her kick out and treat this as a muscle energy for her quads, right? And treat it that way. Or we could work her quads from this position, do either soft tissue or myofascial release or whatever you want to do. So we can address that. By the look of her femur, we can see if she has tight adductors, right? Adductor complex. Or if she's out this way and has tight glutes. So if she has TFL, IT band type problems. So IT band folks are going to drop this leg off the table and it's going to be way over here because their sort of lateral stabilizers are going to be particularly tight. And again, from this position, you can just come right into the table and stretch this right across the way, right? And either have her push out and treat this like a muscle energy or whatever version of that you want to do. Also, if we look at the femur coming down and the tibia heading down off of that, they should be roughly over top of one another, right? So if she has tight piriformis, what you'll see is that the ankle will swing medial and the knee will swing lateral into external rotation. She doesn't have that, but you'll see that the leg will come down into external rotation and that'll tell you that this person has a tight piriformis. And again, right from this position, you can bring the leg into internal rotation and treat it in muscle energy right in that position. And so theoretically, once you've done your initial maneuver with the leg and then you've brought it off the table and just sort of looked at it and figured out what things are tight or not tight. And then you can go through and treat them sort of step by step. And then we would bring this knee back up and we could switch sides. And then we would come up here and we would check the... Oh, good. All right. So she's a runner. That's obvious. Okay. So we would check this hamstring and then drop this off the table and we would take a look. So now on this side... So it's interesting. She's actually got a bit of an asymmetry side to side. So this, for the folks who are sort of over here, you might be able to see. On this side, this is very much IT band, right? So she's way over here on the side. Can you guys see that from where you're at? Yeah. So this is IT band on the left. She didn't really have this on the right. And so it's also interesting because it raises questions, right? So we can start asking her about, like, so where do you run? Do you run on the street? Are you a street runner? Curb runner? Sidewalk? Treadmill? Yeah. And then we might ask about her footwear or other things just to try to understand, like, why this is like this. So, you know, we... Thanks for that. So we can, you know, open up a dialogue based off of what we find on the leg. And so once we go through... And here, we'll switch you back. We'll switch you back up. Here we go. Thank you. Thank you for that. That was awesome. And so based on just that quick maneuver and just seeing what the leg does and then treating accordingly, like I said, we can pretty much handle, you know, most of the muscle imbalance in the lower limb that's going to potentially affect the low back. And for a lot of folks, just doing that is sufficient to help alleviate their low back pain. And it also can help you guide you in terms of, like, a home stretching regimen or home exercise regimen, right? Because if you just see it, oh, these things are tight. Okay, here's what you need to work on at home to try to rehab this problem. So, like I said, kind of an elegant solution. A quick move gets us through a lot of different things and helps us to evaluate the lower limb pretty well. So any questions on that before we turn you loose and have you try it out? Okay. We got tables up here. We got tables on the side. We got tables in the back. So I definitely encourage you to partner up, try it out, and I will walk around and answer questions at the tables if you have them, and we'll work through it. You all right? What's that? Oh, well, that's pretty sweet. You can change it, you know, if you need to, to address more one or the other. Yeah, they're going to come down. Yeah, you could do that, too. That's totally fine, and you can modify this to get that for sure. Yeah, and if you need to, if it's an older patient, you might need to assist them into the position. Definitely doable. Awesome. Yeah. Oh, boy. What's up, man? We can turn it off just because I'll be, and then we'll come back. Mm-hmm. I was born in this place, it's a quite different place. Okay, it looks like people are mostly finishing up. Okay, it looks like people are mostly finishing up with what they're doing. If you're still working, that's fine. If you want to just stay where you are by the tables, we can do that, and I'll just show you the next thing from up here. Can we switch to the slides for a second? No, you're good, you're good. You are good. Okay. Great to see everybody up and doing. Makes my osteopathic heart happy. We did our modified Thomas test, so we should have a decent handle on the lower limb and have it approaching symmetrical in terms of tone. The other piece that we're going to need to address is the lumbar spine. We want to look at the lumbars and try to get them moving. Move number two for our protocol for today is our supine HVLA, also known as Chicago roll or OB roll, depending on who you ask. This is an old classic. Probably many of you know this technique, so no mysteries here. But good because it's a nonspecific mobilization. Don't really need to diagnose all that much. Just sort of do it and whatever goes, goes, right? So again, we were trying to make it ridiculously simple in the sense that we don't have to think that much. We just do. And, you know, by the time we're done, you know, most of the back pain that we see will be at least improved and we have some insight moving forward. So this is a review technique. I'm sure most of you are familiar with this one. But we'll go over it. If you want to practice it at the tables, you're certainly welcome to, but we'll move much more quickly through this one just because it's one that we're familiar with. Can I bar you again? Is that all right? So I'm actually going to have you put your head on this end if that's okay. What's that? Put your head up there. So that's the look of it. The rough look of it. And so with the Chicago roll or however we want to name it, we'll call it supine lumbar HVLA. Does sound like a sushi. It's kind of good. So with this, all we need is a side. Which side do we want to address? And so in this case, if I was going to be treating her right side, let's say, just so that you can see what this is going to look like, then it would be her right side, it would be my right hand, and I'm going to stand on the right side of the table, right? So everything is sort of pushed to the one side. And then Jennifer, I could have you interlock your fingers behind your head. And so it's going to be my right hand, her right elbow, and I'm treating her right side. And so I'm going to hook my hand through her elbow through here. Some people place the back of the hand onto the sternum, which can work. Or you can pull up on the elbow this way. So either way works, but we're just stabilizing the shoulder girdle somehow. So in her case, I'm going to pull up slightly. And then we're going to walk around the table, and I'm going to put my hand on her ASIS on the right. And I'm just going to keep walking down and roll her up off the table like so. And we got two or three out of that just from that quick maneuver. And then we would repeat, rinse and repeat, on the opposite side. So depending on how you run that maneuver, you can aim higher or lower in the lumbar spine. Theoretically, you could get into the lower thoracic spine, too, if you were coming more lateral with your rolling of it, right? So I'm not going to actually do it. I just want to show what I'm talking about. Because from this position, I can roll more down and lift her up, which would be more towards the lumbars. Or I could pull across this way towards me, which is going to stay a little bit higher and try to mobilize a little higher up into even the lower thoracic spine. Or you can start lateral and then move your way inferior and get both of them at the same time. So again, thinking about technique and how we pull this out, off, we would come towards me. And then we would go down. And we would capture our way down. Now again, what did I just treat? I have no idea, right? This is a very nonspecific treatment. I would just pick a segment to write on the, I think that was all three. Sure. Let's go with that. And we know that it's rotated right. That's about it, right? So it is a very nonspecific treatment. But again, ridiculously simple. We're just trying to mobilize the lumbar spine so we can move on. So if you would like to give this one a go, we can do that. Obviously, lumbar HVLA, we have a set of potential contraindications. So if it's a post-operative patient, or they have hardware in there, or fusion, or other issues, we want to talk to our patient and find out if this is an appropriate thing to do or not. But if they're able to tolerate HVLA, this is a good option to try to address that. Yes, ma'am. Is there any contraindication to arthritis? Arthritis not in and of itself. So arthritis by itself, no. If anything, it may help restore some mobility to that joint if it's restricted. Osteoporosis. Osteoporosis is an obvious one, right, if that's a problem. Yeah, Larry. Do you ever modify that to a muscle under treatment, not taking them all the way through? Just hold and then have them try to roll back? Yeah, you could absolutely do that. So that would be treating essentially like the long lever, like erector spinae type musculature? Yeah, absolutely. That would be perfectly reasonable. Okay, very good. So if you want to give that a go and roll each other around, let's do that. And then we'll go through one more. We'll just leave this like that. That's fine. There you go. Nice. He's coming for you. Ah, okay. So don't beat him up too bad. It's actually pretty helpful. What's that? Go ahead and breathe in. Oh, yeah. Okay. For the fixed height. That's awesome. Like coming under and then walking or coming that way? Nope, this way. From the outside. So this would be here. Yep. Under there. And then you're going to stabilize this head. Yep. And you pull them, roll them up off. So my first attempt, I didn't really get that separation. Like holding it like this, do you find it easier coming under? If you can do it that way. No, actually, what I would do is even go further. I would come all the way under here. Right? And now you can just roll them. Yep, there you go. There you go. Okay. So I really tried. Yeah, absolutely. Awesome. Thank you. Mm-hmm. I guess would be being more targeted towards group dysfunctions, as opposed to what we're doing, which would be more towards the type two, single odd things. Honestly, you're going to just mobilize everything. Yeah. You're getting them all anyway? What's that? You're going to get them all. You would just do both sides. So even if it's a group, and you have things that are opposite, you're going to just get it when you go to the other side. People who neglect this culture, they do not like that. They use that as an excuse not to do anything about it. It's like somebody's waiting on you. Yeah. Or exactly. Somebody with so much fibrosis is most likely to do that. Yeah. So for me here, I'm not going to do that. Okay, so we are two-thirds there. In the interest of time, I've got one more to show you. Okay, if you want to just stay at the tables, that's fine. We'll just demo this and then we'll move on. So again, the one thing we have left that we have not addressed is the sacroiliac joint. So we've done the lumbars, we've done the lower limb, but we have not addressed the pelvis. And this is where it all falls apart, because now you've got to do these tests and things and diagnosis, and nobody wants to do that. So the question is, how do we get through a technique that would meet our criteria of minimal diagnostic wherewithal and reasonable chance of being effective, right? So we're going to show you an SI articulatory technique, which is a, again, nonspecific reset of the sacroiliac joint. So whether that's a sacral torsion in a pelvic rotation or a shear, I don't even care, right? It doesn't matter. We're just going to reset that relationship between the anomina and the sacrum. And again, do you need to know how to do all those things? Yes, absolutely, right? Because there is going to be a subset of people who you do this shotgun maneuver and it's not going to solve the problem, right? And so in those cases, then you have to go through and do all the things and figure it out exactly what's going on with this patient. But if doing this sort of quick maneuver takes, you know, a good chunk of those off your plate, right, you don't have to spend all that time and bandwidth figuring everything out. You just sort of maneuver it. And then if it's still a problem, then you go through what you already know and sort of go through all the steps of diagnostics and treatment and be more specific about it. So this is what it kind of looks like somewhat. So we're going to be moving this leg around. The good news about this one, so if you have a, you know, I practice in Texas and everything is bigger in Texas, including the patients. So you know, if you have a Texas-sized patient, this could be potentially problematic. The good news about this particular one is that it doesn't have to be passive. So you can have the patient move their leg with you, kind of like a dance. So it can be an active assist so that you don't have to support the weight of an entire leg, you know, just on your body. If you can do it, like if it's a smaller patient and you're a bigger practitioner, go for it. Great. You just have them relax and do it. But you can absolutely modify this into active assist and have the patient help you out with that. So don't feel gun-shy on this one just because it requires some leg moving. You can modify it. Do you mind being a patient? Okay, great. So what I'm going to do is put you on your side facing that way. Okay, great. So again, the only diagnostic process here is choosing a side, right? That's all we have to do. So I'm going to treat her left SI joint, I'm going to reset her left SI joint. That's the extent of my thought process on, you know, diagnostics for this, okay? And so what we're going to do, I'm going to have you scooch towards me. So like kind of, yep, there you go. Just like that. Okay. And so what we need to do is lock out her SI joint or really her sacrum. So what I'm going to do is hip check her. So I'm going to take my ASIS and kind of hip check her PSIS. So from the side, I'm going to come here and just kind of lean into her like that to put her pelvis against mine like that. And then what I'm going to do is interlock my fingers like so and grab a hold of this knee. Okay. And again, looks bad, but in terms of like lifting and things, but I can have her just kind of abduct your leg for me. So she can absolutely help me with this if we want to do it that way. And then I'll talk about it first and then I'll do it just because there's a little, it requires a little doing. So there's going to be a couple of things happening here. Number one, with this hook on her knee, I'm compressing. So I'm pulling her femur and I'm compressing down the shaft of her femur and pushing her pelvis into me that way. And then we're going to flex kind of like a Faberge type maneuver, right? We're going to flex and then abduct and it's like rowing a boat, got to like row her leg around you. So, but as we move through this range of motion, we got to keep that compression through that entire range of motion. So it's a little complicated just in the sort of managing of that, because as you're moving, you have to change your angle of compression to stay with it. So that's probably the trickiest part of this. But once you sort of get a feel for how that works, it's very straightforward to do. So we're going to come here, I'm going to compress, and then we're going to bring her knee up and around and back and back down. And then we're going to compress and we're going to do a couple of passes of that. And again, so now you felt that motion. So what I want you to do is do it with me. So as we move, yep, just trying to lift your leg. So she's helping me now and I'm barely applying any effort at all to this. She's basically doing the motion of this. And so you can do two or three passes of that and then have her flip the other way and do it the same thing to the opposite side. And you've essentially reset the pelvis, right? Both sides of the pelvis. If you do this maneuver, probably, you know, in a good chunk of those, you're going to hear an audible articulation as the sacroiliac joint actually just physically resets. If you hear that or feel that, just give, then you're done, right? Just job well done. Okay. So you don't have to like keep going. And so if you feel something articulate as you go, great, you just move on, move to the other side and carry on. But again, that's it. So you just a couple of passes with that. If you do it and it still feels a little bit tight to you, which you'll typically see as you start. So for her, when we just did that, when we were here, she felt great. As soon as I started to like lift in this portion of that motion, that's where all her restriction was. Like, it was like, oh my gosh, really hard through that range. Once I passed through that, then it was easy motion again. So she had a little like zone of restriction right through here. So if I were going to do a couple of passes, I would try to emphasize like that portion of that range of motion to try to really improve the range. So another thing that might happen is as you're going through it, you'll just notice that it gets easier and easier to do as the SI joint frees itself up. So yeah. Barry. When you examine the patient and let's say their right is higher than their left, does it make a difference which one side you start on? Yeah. I mean, if you had a sense that one side was tighter than the other, then I would start with that. But honestly, if you're going to do both anyway, you don't really have to think about it that hard. If you want it to be like at least a little more efficient about it and just do some either a flexion test or something and just say, oh, it's positive on the right, so I'm going to just do it on the right, great. Right? Honestly, the technique itself doesn't take that long to just do both sides. So for the medical students in the room, I am not advocating that you stop diagnosing people or anything like that, right? This is OMM for low back pain made ridiculously simple, so we have very specific parameters that we're trying to operate under right here where we're saying, how can we get a back mobilized in a way that is quick and effective and doesn't require a lot of diagnostic thought? That's all we're trying to accomplish through the course of this session. I would, if you are interested in actually finding out what's going on with the patient and doing a more thorough diagnosis, I highly encourage that type of work. Oh, you can sit up. He used to show me how to save my rotator cuff, which I'd torn. I couldn't lie down there again. By all means. The reason I'm showing you is I used to do it with my thumb, and it really had to stay on the hip. Now what do I do? It's going to come off. And so this has really helped me out tremendously and probably you all too. So I just wanted to thank you. Thank you. Appreciate it. OK, so give that a go. And so theoretically, if we've done those three maneuvers, you will have normalized muscle tone in the lower limbs. You will have mobilized the lumbar spine. And you will have reset the sacroiliac joints bilaterally over the course of these three maneuvers. So we have about five minutes left. So just in the interest of time and keeping on schedule, we'll stop there. That's my time. I appreciate your enthusiasm. Does anyone have any specific questions before we break? Coding and billing. He has one. What's that? Coding and billing. We'll talk offline about coding and billing. That's it. Great. Thank you so much, everybody. Please join me in thanking Dr. Servi. That was a great lecture. Thank you. Really helpful.

osteopathic manipulative medicine

musculoskeletal back pain

Modified Thomas Test

supine HVLA technique

sacroiliac articulatory method

Dr. Saj Servey

back pain management

Performing Arts Medicine Fellowship