Nicholas Ch14 BLT

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14 Balanced Ligamentous Tension and Ligamentous Articular Strain TechniquesTechnique Principles

Balanced ligamentous tension (BLT) and ligamentous articular strain (LAS) techniques may be considered as two separate techniques or as one. The history of the development of these techniques probably started during A. T. Still's time, but developed greatly through the work of a number of osteopathic physicians including, but not limited to W. G. Sutherland, DO; H. A. Lippincott, DO; R. Lippincott, DO; R. Becker, DO; and A. Wales, DO (1,2). It appears that a geographic separation and minimal contact between two groups may have caused the same technique to be known by two names. Those in the central United States (i.e., Texas) eventually promoted the term LAS, and those in the northeastern United States (i.e., New Jersey and New England) promoted the term BLT. As the two names suggest, some variance in the techniques developed, and the practitioners developed their own particular nuance for the application of the treatment. The term LAS seems to describe the dysfunction, while the term BLT describes the process or goal of the treatment.

Sutherland may have been most responsible for the technique being taught in early osteopathic study groups. In the 1940s, he began teaching a method of treatment of the body and extremities with the principles promoted for the treatment of the cranium. He talked about the joint's relation with its ligaments, fascia, and so on (ligamentous articular mechanism), and we can extrapolate this to include the potential for mechanoreceptor excitation in dysfunctional states. One of Sutherland's ideas, a key concept in this area, was that normal movements of a joint or articulation do not cause asymmetric tensions in the ligaments and that the tension distributed through the ligaments in any given joint is balanced (2,3). These tensions can change when the ligament or joint is stressed (strain or unit deformation) in the presence of altered mechanical force. Today, this principle is similar to the architectural and biomechanical (structural) principles of tensegrity, as seen in the geodesic dome of R. Buckminster Fuller and the art of Kenneth Snelson, his student (4,5,6). This principle is commonly promoted in the postulate that an anterior anatomic (fascial) bowstring is present in the body. The theory is that the key dysfunction may produce both proximal and distal effects. These effects can produce symptoms both anteriorly and posteriorly (1).

One of the aspects mentioned in some osteopathic manipulative technique (OMT) styles is a release-enhancing mechanism. This mechanism may be isometric contraction of a muscle, a respiratory movement of the diaphragm, eye and tongue movements, or in the case of BLT or LAS, the use of inherent forces, such as circulatory (Traube-Hering-Mayer), lymphatic, or a variety of other factors (e.g., primary respiratory mechanism) (2). The physician introduces a force to position the patient so that a fulcrum may be set. This fulcrum, paired with the subsequent lever action of the tissues (ligaments), combines with fluid dynamics and other factors to produce a change in the dysfunctional state. In some cases, the technique is used to affect the myofascial structures. In the case of treating a myofascial structure, the differentiating factor between BLT/LAS and myofascial release (MFR) is that an inherent force (fluid model) is the release-enhancing mechanism in BLT/LAS; in MFR, the thermodynamic reaction to pressure is the primary release factor.

Technique Classification

Indirect Technique

In the case of BLT/LAS, the physician positions the patient's dysfunctional area toward the ease barrier. This

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indirect positioning is the classic method of treatment in this technique. However, some LAS techniques are exactly like MFR direct techniques, and those are included in this chapter rather than Chapter 8, on myofascial release (1).

When beginning the treatment, the physician typically attempts to produce some free play in the articulation. This attempt to allow the most motion to occur without resistance is termed disengagement. It can be produced by compression or traction (1). Exaggeration is the second step described. It is produced by moving toward the ease or to what some refer as the original position of injury (1). Placing the tissues in an optimal balance of tension at the articulation or area of dysfunction is the final positioning step of this technique. Some refer to this point as the wobble point. This is similar to the sensation of balancing an object on the fingertip. The wobble point is central to all radiating tensions, and those tensions feel asymmetric when not at the point. While holding this position, the physician awaits a release. This release has been described as a gentle movement toward the ease and then a slow movement backward toward the balance point (ebb and flow).

For example, if the dysfunction being treated is described as L4, F SL RL, the ease or direction of freedom is in the following directions: flexion, side bending left, and rotation left. Moving L4 (over a stabilized L5) in this direction is described as moving away from the restrictive barrier and therefore defines the technique as indirect.

Direct Technique

LAS sometimes varies; it can be performed as a direct technique when the musculature is causing a vector of tension in one direction, but to balance the articulation it feels that you are moving toward the direct (restrictive) barrier. It follows the direct style of MFR technique described in Chapter 8. Speece and Crow (1) illustrate this in their book as techniques used in dysfunctions of first rib, iliotibial band, pelvic diaphragm, and so on.

Technique Styles

Diagnosis and Treatment with Respiration

In this method, the physician palpates the area involved and attempts to discern the pattern of dysfunction with extremely light palpatory technique. This could be described as nudging the segment through the x-, y-, and z-axes with the movements caused by respiration. Therefore, the movements used in the attempt to diagnose and treat the dysfunction are extremely small.

Diagnosis and Treatment with Intersegmental Motion Testing (Physician Active)

In intersegmental motion testing/treatment style, slightly more motion and/or force can be used to test motion parameters in the dysfunctional site and to begin to move the site into the appropriate indirect position of balanced tensions. There may be more compression or traction in this form as well, depending on the dysfunctional state, site, or preference of the treating physician.

Indications

Somatic dysfunctions of articular basis

Somatic dysfunctions of myofascial basis

Areas of lymphatic congestion or local edema

Relative Contraindications

Fracture, dislocation, or gross instability in area to be treated

Malignancy, infection, or severe osteoporosis in area to be treated

General Considerations and Rules

The technique is specific palpatory balancing of the tissues surrounding and inherent to a joint or the myofascial structures related to it. The object is to balance the articular surfaces or tissues in the directions of physiologic motion common to that articulation. The physician is not so much causing the change as helping the body to help itself. In this respect, it is very osteopathic, as the fluid and other dynamics of the neuromusculoskeletal system find an overall normalization or balance. It is important not to put too much pressure into the technique; the tissue must not be taken beyond its elastic limits, and the physician must not produce discomfort to a level that causes guarding. It generally should be very tolerable to the patient.

General Information for All Dysfunctions

Positioning

The physician makes a diagnosis of somatic dysfunction in all planes of permitted motion.

The physician positions the superior (upper or proximal) segment over the stabilized inferior

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(lower or distal) segment to a point of balanced ligamentous tension in all planes of permitted motion, simultaneously if possible.

This typically means moving away from the barrier(s) to a loose (ease) site.

All planes must be fine tuned to the most balanced point.

Fine-tune: Have patient breathe slowly in and out to assess phase of respiration that feels most loose (relaxed, soft, etc.); patient holds breath at the point (it may be only partially complete inhalation or exhalation) where the balance is maximal.

Treatment

At the point of balanced ligamentous tension, the physician adjusts the relative position between the superior and inferior segments to maintain balance.

This typically means shifting the top segment continuously away from the direct barrier to prevent the tissues from tightening as they release.

The tissues, as they release, are often described as if they are melting or softening.

Tissue texture changes should occur during the release; if they are not palpated, the position of balanced ligamentous tension has not been set.

When a total release is noted, the physician reassesses the components of somatic dysfunction (tissue texture abnormality, asymmetry of position, restriction of motion, tenderness [TART]). The physician repeats if necessary.

The shorthand rules for this are as follows (1):

Disengagement

Exaggeration

Balance until release occurs

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Cervical Region: Occipitoatlantal (C0C1, OA) Dysfunction Example: C0-C1 ESLRR*

1. The patient lies supine and the physician sits at the head of the table.

2. The patient is far enough away to permit the physician's