OPP Exam 2
What does side bent left cervical look like?
easier to push to the right (into the cave) side bent = 2 arms reaching to that side, cave on other side
Ribs 9-12 CostoVertebral Articulations
Inferior shift of facets as you move down the spine until you only have one instead of 2 single facet = more flexibility •9th Rib has a small articulation with the 8th vertebra and larger articulation with the 9th vertebra •10th -12th Ribs only articulate with a single vertebra, each slightly more inferior than the one before
A 14-year-old male patient presents to the clinic with his mother after he fell off his scooter while wearing a helmet. An x-ray and full H&P show no abnormalities.The physicians notes that ribs 4-7 on the right move further into exhalation than the left. What is the most appropriate diagnosis? Inhalation dysfunction rib 7 Exhalation dysfunction rib 7 Inhalation dysfunction rib 4 Exhalation dysfunction rib 4
Inhalation dysfunction rib 7
A 47-year-old female presents with constipation. Structural exam shows somatic dysfunction in the sacrum and in the lower thoracic spine. Which area would you treat to address her symptoms?
Lower thoracic spine : sympathetic Parasympathetic = Sacrum Constipation = slowing down of peristalsis = sympathetic problem Lower thoracic spine = sympathetic Hyperfiring much more common then underfiring Sympathetic overdrive = slow down secretions and peristalsis Somatic dysfunction in sacrum also could cause diarreha
Post isometric vs recipricol inhibition
PI: use agonist: Push towards neutral / away from restriction = towards freedom *Post civil war = freedom for the slaves? RECIPROCAL INHIBITION: Patient moves towards restrictive barrier (uses antagonist muscle)
Which of the following is the primary motion at the Atlantoaxial joint? a. Rotation b. Sidebending c. Flexion and Extension
Rotation
A 24 year old female presents with severe menstrual cramping and menorrhagia. She has a prior diagnosis of endometriosis. At which spinal level would you likely find a facilitated segment? A.T7 B.T8 C.T9 D.T12
T12 Uterus: T10-L2
Costal Facets
Articulate with articulat facets of ribs: Superior one connects to costal demifacet of vertebrae above, inferior conncects to superior demifacet of corresponding #
C2 could be the vertebra C2 or it could be the shorthand for the interaction of C2 on C3. C2, therefore, is an ___________ vertebra, but is a/an ___________ vertebral segment
C2 is an atypical vertebra, but is a typical vertebral segment -The articulation of C2 on C3 follows typical cervical mechanics For C3 and below, both the vertebrae and the articulations are considered typical Confusing issues: -C1 (articulation) is also the AA (atlanto-axial junction (no-no): C1) -C2 vertebra is atypical, C2 articulation is typical
As you check sidebending of C2 - C7, you note that C4 translates significantly less to the left than to the right. C4 is sidebent ______ and rotated ______ Better with extension:
C4 Extended, Rotated left Sidebent left Pseudo Type 11
In treating a patient for a cervical spine somatic dysfunction, the patient is placed into a position of flexion, left sidebending, and left rotation. From here, the patient is asked to return to neutral against resistance. After 3-5 seconds, the patient is passively moved further into the barrier. Which of the following is a possible diagnosis for the described treatment? a. C3 Flexed, Rotated Right, Sidebent Right b. C7 Flexed Rotated Left, Sidebent Left c. C5 Extended, Rotated Right, Sidebent Right d. OA Flexed, Rotated Right, Sidebent Left
C5 Extended, Rotated Right, Sidebent Right
Cranial Nerve _ (Facial nerve) is responsible for PNS stimulation that causes increased mucosal secretions in the sinuses and nasal cavities.
Cranial Nerve 7 (Facial nerve) is responsible for PNS stimulation that causes increased mucosal secretions in the sinuses and nasal cavities.
A 22-year-old female comes to the clinic with a complaint of frequent headaches. When performing your osteopathic examination, you find that C6 does not translate as well to the left, but this resolves in flexion. How would you set her up to treat this with muscle energy? A.F SlRr B.F RlSl C.F RrSr D.E RrSr E.E RlSl F.E SrRl
D. E RrSr The diagnosis would be C6 F RlSl. To set her up for treatment, we will place her in the opposite of the diagnosis: E RrSr. Options A and F would be examples of an OA diagnosis (pseudo-type 1).
A patient presents to your clinic with a mild irritating cough for several weeks. You diagnose him with an exhalation dysfunction of ribs 7-10. Which rib is the key rib and what muscle will you activate during your treatment with muscle energy? A.Rib 7 - Serratus Anterior B.Rib 7 - Pec Minor C.Rib 10 - Lattissimus Dorsi D.Rib 10 - Quadratus Lumborum
Exhalation dysfunction: key rib is 7 -> Serratus Anterior
Exhalation dysfunctions are stuck: *Restricted ___________/ ribs stop sooner during ________ Inhalation dysfunctions are stuck: *Restricted _________/ ribs stop sooner during ________
Exhalation dysfunctions are stuck down *Restricted inhalation/ ribs stop sooner during inhalation Inhalation dysfunctions are stuck up *Restricted exhalation/ ribs stop sooner during exhalation
During inhalation, a patient's ribs 4-9 on the left are noted to move further into inhalation than the right. What is the most appropriate diagnosis? Inhalation of dysfunction of rib 4 on right Exhalation of dysfunction of rib 4 on right Inhalation of dysfunction of rib 4 on left Exhalation of dysfunction of rib 4 on left
Exhalation of dysfunction of rib 4 on right
Sacral Parasympathetic Nerve Exit though: Form the: Join the: Ascend to the___________ and then ascend to the ___________ Innervate the:
Exit from S2 - S4 sacral foramina Form the pelvic splanchnic nerves Join inferior hypogastric plexus, ascend to the superior hypogastric plexus, then ascend to the inferior mesenteric plexus Innervate the: •Left half of the transverse colon, descending colon, sigmoid colon, rectum •Kidney •Bladder Reproductive organs
Pelvic Splanchnic Nerves Exit from:
Exit from sacrum at S2-S4 •Malposition of the sacrum can put pressure or traction on these nerves (and cause them to increase firing -> Increased peristalsis (diarrhea), effects on bladder, and kidney Treatment focus: Sacrum
You have another patient come in complaining of neck pain and stiffness. Upon screening this patient's neck you find that C4 resists translation to the right and the motion improves when you extend their neck. How would you have the patient direct their force if you were to treat this dysfunction with post-isometric relaxation? Flex, Side-bend left, Rotate right Flex, Side-bend left, Rotate left OE. Extend, Side-bend left, Rotate right Extend, Side-bend right, Rotate right Extend, Side-bend right, Rotate left Extend, Side-bend left, Rotate left
Extend, Side-bend right, Rotate right
During your Osteopathic Structural Exam of a healthy 23-year-old female, you diagnose the occipitoatlantal joint as OA Flexed, Rotate Right, Sidebent Left.Which of the following is the correct initial setup for post-isometric relaxation muscle energy for this patient's somatic dysfunction? a. Extension, Right Rotation, Left Sidebending b. Extension, Left Rotation, Right Sidebending c. Flexion, Right Rotation, Left Sidebending d. Flexion, Left Rotation, Right Sidebending
Extension, Left Rotation, Right Sidebending
Motion of the Diaphragm External Intercostals Contract: Normal Excursion of Diaphragm = ___% Central Tendon is Pulled ________ During Inhalation
External Intercostals Contract Elevating Anterior & Lateral Ribs Normal Excursion of Diaphragm = 60% 1-2.5 cm in quiet breathing 3.6-9.2 cm in deep breathing Central Tendon is Pulled Down During Inhalation Exhalation: Relaxes, returns downward Inhalation: Contracts, pushes up
Diagnosis of the AA
Flexion moves the facet plane horizontal facilitating rotation up to a certain point But, flex the neck to 45 degrees, posterior neck ligaments will tighten and can prevent rotation in C3-7 So, flex past normal and lock out other typical cervicals to just look at AA rotation •Nod the OA into flexion to eliminate OA rotation •Flex the neck to 45 degrees to eliminate C3-C7 rotation •Maintaining the above, rotate the head to the right and left •A positive diagnosis = significant restriction of rotation to one or both sides Alternative method: Lock out OA and C3-C7, then place fingers over the articular pillars of C2 and rotate head *Palpate: When AA reaches its rotational barrier, the articular pillar on that side goes posterior
Cardinal Motions of Axial Skeleton: Flexion/extension is motion in the _______ plane around a ________ axis Side-bending is motion is the _____ plane around a ________ axis Rotation is motion in the _______ plane around a ________ axis
Flexion/extension is motion in the Sagital (longitudinal) plane around a transverse axis Side-bending is motion is the coronal plane (think corner, slicing into front and back) around a sagital (A-P) axis Rotation is motion in the transverse plane a vertical axis *To remember the axis, think about skewering yourself: -To flex/extend, skewer sideways through midline -To sidebend, skewer from front to back -To rotate, skewer from head to toes
Diagnosing Key Rib: BITE •Once a group of ribs is found to have a restriction, palpate the rib interspaces until you locate the key rib •The key rib, is the rib that is causing the inhalation/exhalation dysfunction. •Thus, treatment of the key rib should return the ribcage to normal function. For inhalation dysfunction, the key rib is the _________ rib For exhalation dysfunction, the key rib is the _________ rib
For inhalation dysfunction, the key rib is the bottom rib *Stuck up (can't come down/ restricted in exhalation) Wider Intercostal Space Below Group (wIIIIde Below = I (Inhalation) bottom rib For exhalation dysfunction, the key rib is the top rib *Stuck down (can't come up--> restricted in inhalation (ribs held/pulled down) Wider Intercostal Space Above Group BITE: Bottom (rib) = Inhalation dysfunction, Top = exhalation
In the diagnosis of C5, you find that it translates more easily to the right than to the right. Another finding that you would expect at that segment is: a. It is more difficult to extend than to flex b.It is more difficult to flex than to extend c. The articular pillar is posterior on the left. d. The articular pillar is posterior on the right.
The articular pillar is posterior on the left. Patient SB left
With your fingers in the occipital sulcus, you find that the left sulcus is more shallow than the right sulcus. With extension, the sulcus depth becomes equal. What is the diagnosis? a)OA E SlRr b)OA E SrRl c)OA F SlRr d) OA FSrRl
a)OA E SlRr Muscle energy = place patient opposite Flex OA, SR, RL (but that s kindof impossible, so pick 1 axis of freedom, use flexion and extension
Approximately 50% of rotation of the cervical spine comes from: a. Antlanto-axial articulation b. C3-7 c. Occipito-atlantal articulation
a. Antlanto-axial articulation B is false because it should be C2-7
On peripheral nerve root testing you find weakness and decreased sensation in the distribution of the C6 nerve root. This nerve exits the spine between: a. C5 and C6 b. C6 and C7 c. C7 and C8
a. C5 and C6
An 8-year-old male presents with cough and wheezing. Palpation of the ribcage shows ribs 7-10 on the right move further and stop later during inhalation than those on the left. What is the key rib that needs to be treated? a. Rib 7 on the left b. Rib 7 on the right c. Rib 10 on the left d. Rib 10 on the right
a. Rib 7 on the left The right ribs move more because they don't have a dysfunction. The left ribs stop sooner and thus inhalation is restricted on the left. This means there is an exhalation dysfunction (with inhalation restricted) on the left Using the BITE mnemonic, the top rib (rib 7) is the rib affected since this is an exhalation dysfunction.
With your fingers lateral to the transverse processes of C1, you find that lateral translation to the left is more difficult than translation to the right. Which of the following diagnoses is consistent with this finding? a)OA E SlRl b)OA E SlRr c)OA E SrRl d)OA F SlRl e)OA F SrRr
b)OA E SlRr Lateral translation will not go to left (pushing into the mountain) Lateral translation to right is easier (pushing into cave) Easier to right = sidebent left Pseudo Type 1 (sidebending and rotation opposite) •if extension makes the sulci (or makes cephalad traction) more equal, then it is an extension dysfunction •if flexion makes lateral translation more equal, then it is a flexion dysfunction
Which of the following methods is best for assessing the Atlantoaxial joint? a. Place the cervical spine in neutral, induce rotation and sidebending. b. Place the cervical spine in 45 degrees of flexion, induce rotation. c. Place the cervical spine in 45 degrees of extension, induce rotation. d. Place the cervical spine in 45 degrees of flexion, induce sidebending.
b. Place the cervical spine in 45 degrees of flexion, induce rotation. ●Nod the OA into flexion to eliminate OA rotation ●Flex the neck to 45 degrees to eliminate C3-C7 rotation ●Maintaining the above, rotate the head into the rotation barrier. ●Have the patient rotate away from the barrier. ●Repeat 3-5 times for 3-5 seconds ●Passive stretch into the barrier at the end. ●Reassess
In the diagnosis of C6, the articular pillar on the right is posterior. Another finding that you would expect at that segment is: a. It is more difficult to extend than to flex b.It is more difficult to flex than to extend c. It is easier to translate left than to translate right. d. It is easier to translate right than to translate left.
c. It is easier to translate left than to translate right. Right more posterior = rotated right Pseudo type 2: rotated and side bent to same side, so you know we are side-bent right Side bent right translates left easier
A patient presents to your clinic with history of pneumonia that was successfully treated with antibiotics but continues with difficulty catching her breath. You diagnose her with an exhalation dysfunction of ribs 6-10. Which rib is the key rib and what muscle will you activate during your treatment using muscle energy? A.Rib 10 - Serratus anterior B.Rib 10 - Latissimus dorsi C.Rib 6 - Serratus anterior D.Rib 6 - Latissimus dorsi
c. Rib 6 - Serratus anterior
Muscle Energy Treatment of OA - Flexion Dysfunction: Have the patient _______ his head against the resistance on the chin
have the patient flex his head against the resistance on the chin Flexion is freedom
Accessory muscles of inspiration
sternocleidomastoid, Levatores Costarum Pectoralis major, serratus anterior "These accessory muscles of inspiration include the sternocleidomastoid, pectoralis minor and major, serratus anterior, latissimus dorsi, and serratus posterior superior muscles. Expiration, in contrast, is a passive process produced by elastic recoil of the thoracic cage."
•Sympathetic nerves have ________ pre-synaptic neurons, so their ganglia are: •Parasympathetic nerves have ______ pre-synaptic neurons and so we are mostly concerned with where they :
•Sympathetic nerves have relatively short pre-synaptic neurons, so their ganglia are near the spine and vertebral and rib dysfunctions are important •Parasympathetic nerves have long pre-synaptic neurons and so we are mostly concerned with where they exit the central nervous system
A 45-year-old male presents with neck pain. Osteopathic exam reveals that the OA is extended and sideslipped left. How would you position him for treatment using Muscle Energy? A.E SlRr B.F SlRr C.E SrRl D.F SrRl
A.F SlRr Sideslipped L is another way of saying sidebent R. Therefore, the full diagnosis would be OA E SrRl. Direct treatment involves positioning the patient into their barrier, which would be OA F SlRr.
Odontoid Process (dens) Atypical Cervicals: C_ (axis) Dens held to the atlas via ____ ligament
Atypical Cervicals: C2 (axis) Articulates with the atlas via atlanto-axial joint Dens held to the atlas via ALAR ligament C2-C3 motion is pretty normal, its C1-C2 motion that is different *Conditiosn like Rheumatoid Arthritis or down syndrome compromise alar ligament = instability -> use caution when treating OA/AA
Parasympathetics Cranial and Sacral Division What does each section provide innervation to?
Cranial: CN 3,7,9,10 *CN 10 = vagus Innervates upper 2/3 of GI tract Sacral Division: S2-S4 Innervates lower 1/3 GI tract
Diagnosis of OA: AA: Typical cervicals:
Diagnosis of OA: by translation of C1 or deep sulcus (flexion/extension component) Diagnosis of AA : flexing neck and noting range of rotation or rotating neck atlas starts to rotate Diagnosis of typical cervical: vertebral translation or rotation (flexion/extension component)
A 40-year-old male with allergic rhinitis sneezes frequently. Structural examination reveals an exhalation dysfunction of left rib 2. When treating with muscle energy, which muscle would be most useful to correct this? A.Middle scalene B.Pectoralis major C.Pectoralis minor D.Posterior scalene
D.Posterior scalene
17 year old patient presents for preparticipation sports physical. On osteopathic examination, he is found to have restricted inhalation of ribs 2-5 on the left. What is the primary motion of the key rib (the rib responsible for the restriction)?
Pump handle
In the initial setup for ME of an inhaled 1st rib, the patient may be positioned in either:
flexion alone or flexion and side bending toward the dysfunction
1st Rib Articulation with Vertebra
First rib: Flatter, thicker Sharp angle of rib head •Single facet on rib head articulates with vertebral body of T1 only •Tubercle articulates with transverse process of T1 (shown in green)
Thoracic levels for : Head and Neck Heart Lungs Esophagus Stomach, gallbladder, liver Appendix Ascending Colon Descending Colon
Head and Neck: T1-4 Heart: 1-5 Lungs: 2-7 Esophagus 2-8 Stomach, gallbladder, liver 5-9 Appendix: T 12 Ascending Colon: T10-11 Descending Colon: T12-L2
If the left vertebrae is anterior, and the patient is neutral (neither flexion nor extension improves it), then they are side bent:
If the left vertebrae is anterior, and the patient is neutral (neither flexion nor extension improves it), then they are side bent left (rotated right) Neutral = side-bent opposite direction of rotation **The side-bending component can be inferred based on the sagittal component
15 year old male presents with 8 days of constipation. He continues to pass flatus but has had no bowel movements over this time period. Where would you most expect a somatic dysfunction to be present? OA T2 T11 Sacrum
This patient's constipation is consistent with hyperactive sympathetics (lack of secretion). The only option that represents a sympathetic innervation of the GI tract is T11.
Cephalad Traction
•The side with the deep sulcus should traction up easily •The side with the shallow sulcus will not easily traction upwards (shallow side resists cephalad)
Buzzwords for rotational components: Which side are we rotated to? Anterior vs posterior TP Deep vs superficial Springy on palpatation vs hard end feel Prominent vs less prominent
"Deep" vs. "superficial" - Superficial = this side is sticking out at you, so the vertebra is rotated that direction. "Anterior" vs. "posterior" - Remember you're standing behind the patient while you're diagnosing them. If a transverse process is described as being "posterior," that means the vertebra is rotated towards that side (it's closer towards you/sticking out at you). "Springy on palpation" vs. "hard end feel on palpation" - The most posterior transverse process is going to have a hard end feel because it doesn't want to derotate "Prominent" vs "less prominent" - This is fairly self explanatory. The more prominent side is the posterior transverse process.
Dorsal Root Ganglion
*Nerve ganglia more susceptible to compression *•cell bodies for both somatic and visceral nociception are located in the dorsal root ganglion *Extension and sidebending can cause facet osteophytes and guillotining of the nerve root Extension can cause the ligamentum flavum to buckle Flexion and rotation predisposes to disc herniation
Rotation Method: Typical Vertebrae (C2-C7) *Posterior on right -> you can rotate further _______ but not further _________
*Posterior on right -> you can rotate further right but not left Place fingers behind articular pillars of vertebra and Push left finger anteriorly to test for right rotation (and vice versa)
Diaphragm Important in: Attaches to (3 things): 3 major openings:
*Respiration •Speech •Blood flow •Lymph movement •Lifting *childbearing *Urination *Defecation •Diaphragm •Attaches to ribs 7-12 •Attaches to L1-3 •Attaches to xyphoid process •3 Major Openings/ Hiatus •Inferior Vena Caval (T8): IVC and R. Phrenic Nerve •Esophageal (T10) *Esophagus, Ant&post vagal trunks, phrenicoabdominal (sensory) branch of left phrenic nerve, esophageal branch of left gastric artery, esophageal tributaries of left gastric vein •Aortic (T12): Aorta, azygos/hemizygous vein, thoracic duct, plexus descending to cisterna chylii
Mechanics of the Cervical Spine *•Type I and Type II mechanics do not apply to the cervical spine Compare AA, OA, and typical cervicals
-OA •When sidebending is introduced, rotation will occur in opposite (pseudo-type 1) direction (SLRR) -AA •Rotation only -Typical Cervicals •When sidebending is introduced, rotation will occur in same direction (SLRL) •C2 on C3 and all below •Motion: -OA: •50 % of cervical flexion and extension -AA •50 % of cervical rotation -Typical Cervicals •Remaining 50 % of cervical flexion/extension & rotation •Pseudo Type 11
Rib Anatomy Rib head articulates with: Tubercle Articulates with: 3 Types of ribs:
12 pairs of ribs Rib head articulates with vertebrae of the same number and one above it *•Posterior rib at approximate level of corresponding vertebral body •E.g. T3 lines up with Rib 3 Tubercle articulates with transverse process 3 Types of ribs: •True Ribs : directly connected to sternum by costal cartilage (Ribs 1-7) •False Ribs are indirectly connected to the sternum •The costal cartilage connected to the costal cartilage of the rib above it •(e.g. rib 10 costal cartilage is attached to the costal cartilage of rib 9) •Ribs 8-10 •Floating Ribs do not connect to the sternum at all -> No costal cartilage •Ribs 11-12 Ribs get thinner as they go down
A 30-year-old male comes to the clinic with a complaint of neck pain. He tells that he was in a car accident a couple of years ago, but has had this neck pain ever since. His previous doctors have gotten imaging and everything appears normal. You obtain consent to do an osteopathic exam and find the area of greatest restriction to be at C1. It does not translate to the right as well as is does to the left, but this gets better in extension. You decide to treat to relieve his pain. What is the initial treatment position to treat with muscle energy? A.F SlRr B.F SrRl C.F RlSl D.E RrSr E.E SlRr
A.F SlRr The diagnosis would be OA E SrRl. To set him up for muscle energy treatment, we will place him in the opposite of the diagnosis: F SlRr because muscle energy is a direct technique. The OA joint (occiput + atlas/C1) exhibits pseudo-type I mechanics. Because it does not translate as well to the right, we know it is sidebent right. This resolves in extension, meaning it is extended (E). We can then assume that rotation will be in the opposite direction of sidebending.
Using the previous patient (Ribs 4-7, exhalation dysfunction), which intercostal space is wider/larger? A.Intercostal Space 3 B.Intercostal Space 4 C.Intercostal Space 5 D.Intercostal Space 6 E.Intercostal Space 7 F.Intercostal Space 8
A.Intercostal Space 3
A 27 year old man presents with complaints of heartburn. History reveals that he has had heartburn in the past but has noticed it more frequently in the past 2 weeks. Structural exam reveals OA E RLSR; C7 F RSR; and T8-10 F RSL. Which area would you treat and why? A.OA to decrease vagus parasympathetic firing B.OA to increase vagus parasympathetic firing C.C7 to increase sympathetic firing D.T8 to increase sympathetic firing T10 to decrease sympathetic firing
A.OA to decrease vagus parasympathetic firing In this case, the patient is experiencing increased gastric secretions due to hyperfiring of the vagus nerve that is causing an increasing in the production of gastric acid.In order to treat this patient, you would focus on treating the OA to reduce the overstimulation of the vagus nerve.
A patient presents complaining of constipation and difficulty taking a deep breath. During osteopathic evaluation, you find there is restriction and tightness around the lower ribs and diaphragm. During motion testing you find that the fascia moves freely when you move it anteriorly, into right sidebending, and left rotation. How would you hold the tissue to treat directly? A.Anterior only B.Anterior, right sidebending, left rotation C.Anterior, left sidebending, right rotation D.Posterior, left sidebending, right rotation E.Posterior, right sidebending, left rotation F.Posterior only
A.Posterior, left sidebending, right rotation - direct, so we place it in all 3 barriers
A 19-year-old male presents to the clinic complaining of pain when he takes a deep breath. He has no past medical conditions and was recently seen for a full sports physical. During your osteopathic exam, you find that there is tenderness to palpation over the left upper ribs. Ribs 2-4 on the left stop earlier during exhalation than those on the right. Which rib would be the key rib? A.Rib 2, exhalation dysfunction B.Rib 2, inhalation dysfunction C.Rib 4, exhalation dysfunction D.Rib 4, inhalation dysfunction
A.Rib 4, inhalation dysfunction - inhalation dysfunction because they stop earlier in exhalation (they like inhalation) so the bottom rib is the key rib (BITE)
A 67-year-old female patient has just been admitted to your floor due to pneumonia. While examining her ribs, you find that ribs 6-9 on the left stop earlier during inhalation than those on the right. Which best describes the rib you would treat to help resolve her dysfunction? A.Rib 6, inhalation dysfunction B.Rib 6, exhalation dysfunction C.The interspace between 7 and 8 D.Rib 9, inhalation dysfunction E.Rib 9, exhalation dysfunction Which muscle would you target to treat the key rib?
A.Rib 6, exhalation dysfunction Target Serratus Anterior: A.Posterior scalene - rib 2 B.Pectoralis major - none C.Pectoralis minor - ribs 3-5 D.Serratus anterior - ribs 6-8 E.Latissimus dorsi - ribs 9 and 10 F.Quadratus lumborum - ribs 11 and 12 The ribs on the left stop earlier during inhalation, meaning that they are stuck in/"like" exhalation. This would be an exhalation dysfunction because we name based on what the rib "likes" to do. By using the BITE pneumonic, we can remember that the TOP rib (rib 6) is the key rib. We treat exhaled ribs 6-8 by using serratus anterior. If this were an inhalation dysfunction, the ribs would stop earlier during exhalation. We would then treat the bottom rib (rib 9).
A 47-year-old female patient presents to your clinic complaining of acid reflux and heart burn. You perform an osteopathic structural evaluation and find that there is a somatic dysfunction of the diaphragm. The tissues soften when you move it posteriorly, into left sidebending and into left rotation. At what vertebral level does the most likely involved structure pass through the diaphragm? A.T7 B.T8 C.T9 D.T10 E.T11 F.T12
A.T10-esophageal hiatus (her symptoms suggest the most likely involved structure is the esophagus)
A 37-year-old male patient presents to your clinic complaining of abdominal pain. While taking a thorough history, you learn his last bowel movement occurred 6 days ago. On osteopathic examination, you find a dysfunction at C1 and a group dysfunction at T7-T11. Which answer choice best describes your treatment? A.C1 to address parasympathetic hyperactivity B.C1 to address sympathetic hyperactivity C.C1 to address parasypathetic hypoactivity D.T7-T11 to address parasympathetic hyperactivity E.T7-T11 to address sympathetic hyperactivity F.T7-T11 to address sympathetic hypoactivity
A.T7-T11 to address sympathetic hyperactivity This patient is experiencing pain due to constipation. Treating C1 would be addressing parasympathetic hyperactivity (which would cause diarrhea, not constipation). "In almost all beginning discussions of treating the autonomics, we will be talking about toning down an irritated, hyperfiring nerve. We stop the artificially triggered firing of the nerve, and let the body's normal regulatory function take over."
What type of rib is rib 3, and what type of movement does it typically follow? A.True rib - Pump handle B.True rib - Bucket handle C.False rib - Pump handle D.False rib - Bucket handle
A.True rib - Pump handle
A 29 year old male presents to the clinic complaining of back pain. You do a Stiles' screen and discover his AGR is T7-9. In relation to the spinous process of T7, at which spinal level will you be able to palpate the transverse processes of T7? A.Between T7 and T8 B.At the level of T6 C.Between T6 and T7 D.At the level of T7
At the level of T6 Rule of 3's T1-3 and 12: TP in line with SP T4-6 and 11: SP half step lower then TP T7-9 and 10: SP full step lower then Transverse process SO if spinous process of T7 is a full step below transverse process, you need to go to T6
27 year old female presents to clinic with complaint of shortness of breath when climbing a flight of stairs. You find left ribs 5-9 do not move into inhalation. Her history and physical exam are otherwise unremarkable. When treating with muscle energy, which muscle would be most useful to correct this somatic dysfunction? A.Anterior scalene B.Pectoralis minor C.Posterior scalenes D.Serratus anterior
B. Pec minor Exhalation dysfunction Rib 5 is key rib
You have a patient come into your office complaining of right upper quadrant pain after eating pizza for dinner last night. The patient has a history of similar attacks after eating greasy foods. You determine that the patient is likely suffering from cholecystitis (inflammation of the gallbladder) due to gallstones. You perform an osteopathic screen find that T8 is sidebent and rotated to the right (facilitated segment). What type of reflex is this? You have a teenage patient coming in with wheezing and shortness of breath. You evaluate the patient and rule out the nasties. You perform an osteopathic screen and find that the right ribs 3-7 have an exhalation dysfunction with a posteriorly subluxed rib 8. Upon further questioning you find out that the teen was in a car accident three weeks ago when he accidentally drove through the wall of an old cabin. You determine that the patient is currently experiencing bronchospasm after this accident. What reflex is causing his symptoms? A. Viscerovisceral Reflex B. Viscerosomatic Reflex C. Somatovisceral Reflex D. Somatosomatic Reflex
B. Viscerosomatic Reflex : Localized visceral stimuli producing patterns of reflex response in segmentally related somatic structures defines? *The radiation of pain to the shoulder that occurs with an MI is an example C. Somatovisceral visceral: sympathetic or parasympathetic afferents (organ causing the problem first, leading to somatic afferents (muscle spindles, golgi tendons, nociceptors, etc.
While palpating a patient's chest during respiration, you notice when the patient inhales, ribs 4-7 on the right do not move up into inhalation as well as those on the left. During exhalation, ribs 4-7 move symmetrically downward. What is the dysfunction? A.Right ribs 4-7 inhalation dysfunction B.Right ribs 4-7 exhalation dysfunction C.Left ribs 4-7 inhalation dysfunction D.Left ribs 4-7 exhalation dysfunction
B.Right ribs 4-7 exhalation dysfunction The left ribs move more because they don't have a dysfunction. The right ribs stop sooner and thus inhalation is restricted on the right. This means there is an exhalation dysfunction (with inhalation restricted) on the right Using the BITE mnemonic, the right top rib (rib 4) is the rib being held down in exhalation, holding the ribs beneath down in exhalation as well. This is an exhalation dysfunction.
A 19-year-old female patient presents to your clinic complaining nasal drainage. She also states that her eyes have been watering more lately. She describes the secretions as clear and watery. Which treatment would you perform based on her chief complaint (assuming there is a dysfunction present)? A.Sphenopalatine ganglion stimulation to increase parasympathetic tone B.Sphenopalatine ganglion release to decrease parasympathetic tone C.Muscle energy to T1-T4 to address sympathics to the head and neck D.Sacral rocking to balance sympathetics and parasympathetics
B.Sphenopalatine ganglion release to decrease parasympathetic tone
In testing your patient for cervical spine somatic dysfunctions, you notice that translation of C5 to the right is easier than translation to the left. C5 is also flexed. What is the correct diagnosis of C5? a. C5 Flexed, Rotated Right, Sidebent Left b. C5 Flexed, Rotated Right, Sidebent Right c. C5 Flexed Rotated Left, Sidebent Right d. C5 Flexed, Rotated Left, Sidebent Left
C5 Flexed, Rotated Left, Sidebent Left: It is moves easier to the right its sideband left because the movement right is easier because you are pushing into the concavity
A 62 year old man presents with neck stiffness for 3 days. There was no inciting incident and no trauma. On exam, the tissue around the cervical spine is boggy and warm. Restriction of motion is appreciated in the lower cervical vertebrae. C5 is restricted in right translation. This restriction is more appreciable in extension. Which of the following is the most likely diagnosis? C5 extended rotated right sidebent right C5 extended rotated left sidebent left C5 flexed rotated left sidebent left C5 flexed rotated right sidebent right
C5 flexed rotated right sidebent right C5 restricted in right translation = left sidebending (he cant do left sidebending) More appreciable = worse Named for freedom: Worse in extension so he is flexed, can't left side bend so he is sidebent right
A 32 year old male presents to the clinic with neck pain. He has had no trauma and no inciting incident. On physical exam, there is a ropy texture of the tissue along the posterior cervical spine. The right articular pillars from C5-C7 are posterior compared to the left. This asymmetry does not resolve with either flexion or extension of the involved segment. What is the diagnosis of the somatic dysfunction? C5-C7 neutral rotated left sidebent right C5-C7 flexed rotated right sidebent right C5-C7 neutral rotated right sidebent left C5-C7 extended rotated right sidebent right
C5-C7 neutral rotated right sidebent left
C6 translates more easily to the left than to the right. With flexion to C6, translation to the right improves, and with extension to C6, translation to the right decreases. What is the diagnosis at C6? •Extended, Rotated left Sidebent left •Extended, Rotated right Sidebent right •Flexed, Rotated left Sidebent left •Flexed, Rotated right Sidebent right
C6 Flexed, Rotated Right, Sidebent Right Easier to left = sidebent right Translation -> think sidebending Pseudo Type 2 (typical cervical so rotation and side bending to same side)
A 58 year old male with a longstanding history of cervical spondylosis presents with neck pain radiating down the right arm after helping a friend move.The patient describes neck pain radiating down the arm into the medial palm and 4th and 5th digits. Physical exam finds intact strength and sensation in the right and left upper extremities, and restriction of motion in the lower cervical spine. Which of the following dysfunctions is most likely to be present in this patient? C6 neutral rotated left sidebent right C5 flexed rotated right sidebent right C7 neutral rotated right sidebent right C8 extended rotated right sidebent right
C8 extended rotated right sidebent right
78 year old male presents to clinic with complaint of shortness of breath when climbing a flight of stairs, increased coughing and history of COPD. You find all of his ribs are restricted in exhalation, but right ribs 1-6 have the most restriction. What muscle is most likely hypertonic, holding the somatic dysfunction in place. What is the initial set up to treat this dysfunction with muscle energy? A.Patient supine, hand on forehead, lifting head B.Patient supine, hand over head, pushing elbow up C.Patient supine, flexed to level of dysfunction, pressing chin to chest D.Patient supine, sidebent to level of dysfunction, reaching for foot
D.Patient supine, sidebent to level of dysfunction, reaching for foot
Diaphragm Attachments (3) *Note the expanse of the diaphragm. If restricted, it not only impacts the motion of the lower ribs and upper lumbar spine, it can impact sympathetic innervation, lung expansion, gastric motility.
Diaphragm •Attaches to ribs 7-12 •Attaches to L1-3 •Attaches to xyphoid process
A 37 year old male presents with left arm weakness and neck pain. There was no associated trauma or inciting incident. On physical exam, he is found to haveC7 flexed rotated left sidebent left. Which of the following is most associated with this dysfunction? Diminished Biceps reflex Diminished Triceps reflex Hyperactive brachioradialis reflex Hyperactive biceps reflex
Diminished Triceps reflex
Screen, Diagnose, Treat, Reassess Rib Dysfunctions Overview If it moves into inhalation but won't fall into exhale its an _____________ dysfunction
If it moves into inhalation but won't fall into exhale its an inhalation dysfunction •With the patient supine, palpate the ribcage during deep inhalation and exhalation, monitoring for a group rib dysfunction in each of the five hand positions shown •Determine if the group of ribs are stuck up or stuck down on one side compared to the other (left vs right) •Stuck up = Inhalation Somatic Dysfunction (Doesn't want to exhale) •Stuck down = Exhalation Somatic Dysfunction (Doesn't want to inhale) •Palpate the rib interspaces, comparing side to side, in order to locate the key rib on the side of dysfunction. Bottom rib for inhaled. Top rib for exhaled (BITE) •Treat the key rib •Reassess that group, comparing side to side, for improvement
If you find vertebrae that are rotated left, sidebent right, stand on ______ side because that is where the convexity is *The side-bending component can be inferred based on the ________ component
If you find vertebrae that are rotated left, sidebent right, stand on left side because that is where convexity is *The side-bending component can be inferred based on the sagittal component
Parasympathetic Overview: Innervates: Does not innervate: 2 Divisions: Vagus nerve innervates: Pelvic Splanchnic nerves innervate:
Innervates structures in the: •Head •Thorax (heart, lungs) •Abdomen (gastrointestinal structures) •Pelvis (gastrointestinal, genitourinary) *Everything but the vasculature 2 divisions: •Cranial •Sacral •The vagus innervates thoracic organs and G.I tract up to mid-transverse colon •The pelvic splanchnic nerves (coming out from the sacrum) innervate from the mid-transverse colon to the rectum (includes left side of transverse colon, descending colon, sigmoid colon, and rectum)
A 43 year old male presents with complaint of diarrhea. He explains that he has multiple episodes of watery diarrhea daily for 6 weeks. He has no other symptoms. On osteopathic evaluation, the patient is found to have shallow occipital sulcus on the right, T4 F RrSr, and L5 N SlRr. Which somatic dysfunction would you treat first? OA T4 F RrSr L5 N SlRr Pterygopalatine ganglion
OA The diarrhea is likely a result of hyperfiring of the vagus nerve as a result of irritation of the nerve as it exits the skull caused by the OA dysfunction.
Motion: OA: 50 % of cervical _______ and _________ AA: 50 % of cervical _________ Typical Cervicals: Remaining 50 % of cervical _________, ____________, ____________
OA: 50 % of cervical flexion and extension AA: 50 % of cervical rotation Typical Cervicals: Remaining 50 % of cervical flexion/extension & rotation
Type I and Type II mechanics do not apply to the cervical spine OA: When sidebending is introduced, rotation will occur in ________________ (Pseudo type __) AA: __________ only Typical Cervicals: When sidebending is introduced, rotation will occur in __________________ (Pseudo Type __)
OA: When sidebending is introduced, rotation will occur in opposite direction (SLRR) (Pseudo type 1) AA: rotation only (no-no joint) Typical Cervicals: When sidebending is introduced, rotation will occur in same direction (SLRL) (Pseudo type 2: Two to the Left (rotation and side-bending) = type 2)
Treatment setup for treating an inhalation dysfunction of rib 4? Patient supine with their elbow pointing to the ceiling; physician resists contraction of the pectoralis minor while pulling inferiorly on the posterior rib head. Patient supine with dorsum of hand over their forehead; physician resists cervical flexion while pulling inferiorly on the posterior rib head. Patient supine with head and neck flexed; physician pushes inferiorly on the anterior aspect of the rib to exaggerate exhalation and resist inhalation. Patient prone and sidebent towards the side of the dysfunction; physician rotates pelvis posteriorly while pushing ribs away from their articulation point.
Patient supine with head and neck flexed; physician pushes inferiorly on the anterior aspect of the rib to exaggerate exhalation and resist inhalation.
A 67 year old female presents with right sided chest pain for 3 days' duration. The pain is worsened with deep breathing. On examination, ribs 3-7 on the right do not rise as much in inhalation as on the left. Which muscle is activated during muscle energy treatment of this dysfunction? a. Middle scalene b. Pec minor c. Serratus Anterior d. Quadratus Lumborum
Pec minor
A 22 year old primigravid woman in labor experiences arrest of labor. She is treated medically with no improvement in labor progression. Which of the following structures is most likely inhibited? Lesser splanchnics Pelvic splanchnics Vagus nerve Pterygopalatine ganglion
Pelvic splanchnics: supply autonomic innervation to reproductive organs (&kidney, bladder and lower GI tract) They can be inhibited by pressure from the gravid uterus. Sacral rocking can be employed to stimulate those inhibited nerves. Side note: sacral rocking can also be used to tone down overactive nerves in other context.
Diagnosis of OA: Place fingers in the: If the OA is sidebent right, the _________ sulcus will be more shallow
Place your fingers in the occipital sulcus and compare depth of sulcus: left vs right (fingers b/n occiput and C1: more lateral than usual, C2-C7 palpates articular pillars that are more medial) If the OA is sidebent right, the right sulcus will be more shallow than the left sulcus *Occiput tilted to axis *Rotated left *Pseudo type 1 Shallow = hypertonic muscles (but if you do it yourself it will be the opposite??)
A 26 year old female with a longstanding history of migraine presents with new headache symptoms. Her usual unilateral headaches are present, but with a constant facial pressure for the last 10 days. She notes significantly increased mucus production over the same time period. Which of the following structures is most likely to be involved in her pathology? T8 OA Pterygopalatine /Sphenopalatine ganglion T1
Pterygopalatine ganglion Increased nasal and sinus secretions are mediated by the parasympathetic nervous system via the pterygopalatine ganglion. T1 is one of the levels that mediates sympathetic innervation to the head and neck. Hyperactivity of sympathetic innervation would lead to dry sinuses (lack of secretion).
Using the previous patient (Ribs 4-7, exhalation dysfunction), which rib is the key rib? A.Rib 3 B.Rib 4 C.Rib 5 D.Rib 6 E.Rib 7 F.Rib 8 what muscle will you activate during your treatment with muscle energy? A.Rib 4 - Pec minor B.Rib 4 - Serratus anterior C.Rib 7 - Pec minor D.Rib 7 - Serratus anterior
Rib 4 Because its an exhalation function Inhalation = key rib is largest number Exhalation = key rib is smallest number A.Rib 4 - Pec minor If this was an inhalation somatic dysfunction? What muscles would be holding it in place: Serratus anterior Rib dance used to know what position to treat ribs
A 55 year old male presents with left upper back pain for 4 days. The pain is worsened with deep breathing. On examination, he is found to have a widened intercostal interspace between ribs 3 and 4 on the left. The space between ribs 4 and 5 is narrowed on the left. Which is the key rib? a. Rib 2 left b. Rib 3 left c. Rib 4 left d. Rib 5 left
Rib 4 left
A 33 year old female presents with right sided chest pain for 3 days' duration. The pain is reproducible with deep breathing. On examination, ribs 6-9 do not rise as much in inhalation on the right as on the left. What is the key rib for this dysfunction? a. Rib 6 left b. Rib 6 right c. Rib 9 left d. Rib 9 right
Rib 6 right
A 32-year-old female patient presents to the clinic 2 days after falling off her horse. An x-ray and full H&P is unremarkable. The physician notes that rib 7 on the left moves further into inhalation than the right side. Which of the following is the key rib and its primary mechanism of motion? Rib 6 pump handle Rib 6 bucket handle Rib 7 pump handle Rib 7 bucket handle
Rib 7, Bucket handle
Rib Motion or Restriction Impacts Entire Body Due to Sympathetic Innervation Rib overlies: Attaches to 3 places:
Rib overlies sympathetic chain ganglia -> can impact sympathetic innervation •Diaphragm •Attaches to ribs 7-12 •Attaches to L1-3 •Attaches to xyphoid process If restricted, it not only impacts the motion of the lower ribs and upper lumbar spine, it too can impact sympathetic innervation, lung expansion, gastric motility (can cause constipation)
A 67 year old male presents with several episodes of diarrhea. He has no other complaints. On examination, he has AA rotated right, T8 N SlRr, T11 E RrSr, and a sacral rotation. Which of the somatic dysfunctions listed is most likely related to his diarrhea? AA T8 T11 Sacrum
Sacrum The diarrhea is most likely due to irritation of the pelvic splanchnics from the sacral dysfunction leading to hyperfiring of that parasympathetic innervation to the lower GI tract. Note that hyperfiring of the vagus nerve would also potentially lead to diarrhea by stimulating the upper GI tract. Underactivity of the sympathetics to the gut (ex from T11) is not being discussed in the scope of this course.
A 49 year old male presents with mid back pain for 2 weeks. On physical exam, he is found to have a depressed 7th rib on the right. Which of the following muscles is activated for muscle energy treatment of this dysfunction? a. Middle scalene b. Pec minor c. Serratus Anterior d. Quadratus Lumborum
Serratus anterior
Diagnosing Cervicals using Sidebending How to find C1 Transverse process: Sidebent Left = stick out more/easily translates on ________ If C1 translates more easily to the left, then it is sidebent _________
Sidebent Left = stick out more/easily translates right If C1 translates more easily to the left, then it is sidebent right C1: Tip of transverse process = inferior/anterior to mastoid process
Translation and sidebending
Sidebent right = leaing to right, more parts on the right Easier to push to the left (into the cave of the C)
Treating Autonomics Two exceptions to treating hyperfiring (when are we not treating hyperfiring nerve)
Usually toning down irritated, hyperfiring nerve (tone down sympathetics) •The 2 exceptions to this policy are the sphenopalatine ganglion release and sacral rocking for women in labor
Sympathetic Innervation Mapping: T12-L2 (includes ______ _______ plexus)
•(Inferior mesenteric plexus) •Colon from mid-transverse to rectum and pelvic organs (bladder, uterus, prostate). Uterus: T10-L2
Which of the following are considered atypical ribs? •1, 2, 11, 12 •1, 2, 9-12 •1, 10, 11, 12 •1-3, 11, 12 •1-3, 10, 11, 12
•1, 2, 11, 12 Sometimes 10 considered atypical as well (no demifacet)
Posterior Landmarks
•C7 Vertebra Prominens •T3 Spinous Process: Spine of the Scapula (rib 3) •T7 Spinous Process: Inferior Angle of the Scapula (rib 7) •L4 Spinous Process: Iliac Crest (rib 11-12)
Review of cervicals:
•Diagnosis of OA is either by (a) translation of C1 or (b) deep sulcus •There is also a flexion/extension component •Diagnosis of AA is either by (a) flexing the neck and noting range of rotation (b) rotating the neck until you feel the atlas start to rotate •Diagnosis of typical cervical is by (a) vertebral translation (b) vertebral rotation •There is also a flexion/extension component
•A 32-year-old male presents with diarrhea. Structural exam shows somatic dysfunction in the upper cervical spine and in the lower thoracic spine. Which area would you treat to address his symptoms?
•Diarrhea = hyperfunctioning of parasympathetic NS •Upper cervical spine would treat •Lower thoracic would not treat (its sympathetic)
Direct vs Indirect Treatment
•Direct treatment: Take somatic dysfunction into barrier •Muscle Energy •High Velocity Low Amplitude (HVLA) •Myofascial Release Direct •Indirect treatment: somatic dysfunction into the position of ease (diagnosis) •Myofascial Release Indirect •Balanced Ligamentous Tension •Counterstrain •Functional Release •Mixed treatment modalities include both direct and indirect (Still)
Evaluating Caliper Motion Supine •Ribs 11 & 12 don't attach to the sternum •Because of this, they exhibit caliper motion: •During inhalation they move __________ and _________ •During exhalation they move ___________ and ____________ •Ribs 11-12 also move slightly ________ with inhalation and slightly __________ with exhalation
•During inhalation they move posterior and lateral •During exhalation they move anterior and medial •Ribs 11-12 also move slightly inferior with inhalation and slightly superior with exhalation
2 Common Types of Rib Somatic Dysfunctions Inhalation Dysfunction means restricted in __________ *Stuck ____ Exhalation Dysfunction means restricted in __________ *Stuck ____
•Inhalation Dysfunction means restricted in exhalation •Group of ribs move freely and fully into inhalation; but restricted when descending in exhalation. Stuck up •Exhalation Dysfunction means restricted in inhalation •Group of ribs move freely and fully into exhalation, but restricted when rising in inhalation. Stuck down
Muscles of inhalation and exhalation
•Muscles of Inhalation •Primary Muscles: •Diaphragm contracts •Intercostal Muscles: external, internal, innermost, and subcostal intercostal muscles •Secondary Muscles: •Scalenes, Pectoralis minor, Serratus Anterior & Posterior, Quadratus Lumborum, Latissimus dorsi •Muscles of Exhalation •Primary Muscles: (quiet breathing) •Diaphragm relaxes •Secondary Muscles: (forceful exhalation) •Abdominal muscles: rectus abdominus, external oblique, internal oblique, & transversus abdominus
Disc Herniation: Nerve roots exit spinal cord between : •Most common herniation in cervical spine is: _________ disc (________ root)
•Nerve roots exit spinal cord between corresponding vertebra and one above •C4-C5 disc : C5 root (C5 root exits above C5 and blow C4) •C5-C6 disc : C6 root •C6-C7 disc : C7 root •C7-T1 disc : C8 root •T1-T2 disc : T1 root •Most common herniation in cervical spine is C5-C6 disc (C6 root)
Muscle Energy Treatment of the AA
•Nod the OA into flexion to eliminate OA rotation •Flex the neck to 45 degrees to eliminate C3-C7 rotation •Maintaining the above, rotate the head into the rotation barrier. •Have the patient rotate away from the barrier. •Repeat 3-5 times •Passive stretch into the barrier at the end. •Re-assess
Intercostal Spaces Named by space:
•Numbered for rib superior to intercostal space •Example: 1st intercostal space is between rib 1 & 2
Compression or traction on parasympathetic nerves that could lead to organ dysfunction often occurs in two locations:
•Occipito-atlantal junction affecting the vagus nerve (heart, lungs, stomach, liver, pancreas, small intestine, large intestine up to mid-transverse colon, among others) •Sacrum affecting pelvic splanchnic nerves (mid-transverse colon, descending colon, sigmoid colon, rectum)
•A 27-year-old male presents with gastro-esophageal reflux disease (GERD) from too much stomach acid production. Where would you check for possible parasympathetic cause of his problem? •Occipito-atlantal junction •Sacrum •T4
•Occipito-atlantal junction correct Parasympathetic = too much secretions T4 cant be it because its not part of cranial or sacral Sacrum would be organs way lower
Crural Attachments Medial vs Lateral arcuate
•Originate from anterior lumbar vertebral bodies, intervertebral fibrocartilaginous discs & anterior ligament •Left Attaches L1-2 •Right Attaches L1-3 • Join anteromedially to form Median Arcuate Ligament around the Aortic Hiatus •The Right Crus then splits to form the Esophageal Hiatus •Then moves into the Central Tendon Minor apertures crossing the crura: Greater, lesser, least splanchnic nerves *Azygos and hemiazygous veins (variable) •Medial Arcuate Ligament is Attached to •12th Rib •Lateral Vertebral Body of L1 & 2 •Transverse Processes of L1 •Overlies the Psoas Major •Taut with Rib 12 elevation •Lax with Rib 12 depression •Lateral Arcuate Ligament is Attached to •12th Rib •Transverse Processes of L1 & 2 •Overlies the Quadratus Lumborum
Myofascial Release Direct vs Indirect
•Passive, direct or indirect technique *Applies sustained pressure in barrier or ease and is held until a release or fascial "creep" occurs. •Steps: •Traction or compress the tissue in all three planes; flexion/extention, Sidebending, and Rotation •Wait for a release (~30 seconds) •Goals: •Restore motions •Improve circulation and lymphatic flow •Support visceral function •Active enhancers: Deep Breathing •Myofascial Release can be done directly by taking the tissue toward the barrier/restrictio: Start in neutral and move it away from the position of ease. It will start to bind or get more tense and difficult to move the tissue in that direction •Or Indirectly by taking the tissue toward its position of ease/diagnosis - Start in neutral and move in direction that relaxes the tissue •Done in multiple planes of motion: moving tissue •Inferior/Superior •Medial/Lateral •Clockwise/Counterclockwise •Rotating Left/Right •Sidebending Left/Right •Flexion/Extension
Seated Thoracic Diaphragm Release (Indirect)
•Patient is seated, physician stands behind while patient rests against them •Physician places their hands along lower borders of ribcage, allowing pinkies to curl under costal margins •Physician motion tests rotation by moving hands in opposite direction simultaneously anterior and posterior. Note ease. •Motion test sidebending by moving one hand superior and the other inferior, then test in opposite direction, noting restriction •Place patient into freedom in both rotation and sidebending •Flex the patient forward until you feel further softening of the diaphragm. •Have patient take a breath while resisting motion •After exhalation, move patient further into freedom •Repeat 3-5 times, moving further into freedom each time, with passive stretch at the end •Reassess
Supine Thoracic Diaphragm Release (Direct)
•Patient lies supine, physician stands to the side of dominant eye (left eye dominant, stand on patient's left side ) •Place hands on lower ribcage, with thumbs wrapping under costal margin •Motion test rotation by pulling anterior with one hand at a time, noting restriction •Motion test sidebending by moving one hand superior and the other inferior, then test in opposite direction, noting restriction •Motion test flexion/extension by moving both hands simultaneously in the same direction, anterior and posterior (creating extension and flexion) •Place patient into all 3 BARRIERS •Have patient take a breath, resisting motion •After exhalation, put patient further into barrier •Repeat 3-5 times, moving patient further into the barrier with each breath and ending with passive stretch •Reassess
Summary inhalation/exhalation key rib The rib that stops sooner during inhalation have an ____________ dysfunction •The rib that stops sooner during exhalation have an _________ dysfunction Example: Right upper rib doesn't want to rise/inhale: Right rib ________ dysfunction Expect wider intercostal space ________
•Place fingers on each side of a pair of ribs •The rib that stops sooner during inhalation have an exhalation dysfunction •Inhalation is restricted •It may feel like it moves more during exhalation than during inhalation •The rib that stops sooner during exhalation have an inhalation dysfunction •Exhalation is restricted •It may feel like it moves more during inhalation than during exhalation •The key rib keeps the ribs above or below from completing their normal excursion •Inhalation dysfunction: Key rib (bottom rib) holds the ribs above it up •Exhalation dysfunction: Key rib (top rib) holds the ribs below it down Example: Right upper rib doesn't want to rise/inhale Right rib exhalation dysfunction Expect wider intercostal space above
Rib 1 Inhalation Dysfunction Muscle Energy - Respiratory Assist Supine
•Place the metacarpal-phalangeal joint of the the index finger over the posterior first rib. •Sidebend the head and neck towards side of dysfunction and rotate away. •When the patient exhales, follow the rib down. •When the patient inhales, resist as the rib rises. •Passive stretch, return to neutral •Reassess
•Muscles used for Exhalation dysfunctions: Rib 1 Rib 2 Ribs 3-5 Ribs 6-8 Ribs 9-10 Ribs 11-12
•Rib 1: Anterior and middle scalenes (pull rib up) •Rib 2: Posterior scalene •Ribs 3-5: Pectoralis minor •Ribs 6-8: Serratus anterior •Ribs 9-10: Latissimus Dorsi •Rib 11-12: Quadratus lumborum
Ribs 2-9 Articulation with Vertebrae Tubercle articulates with: •Rib head has Double demifacets that articulate with
•Rib head has Double demifacets that articulate with the vertebra of same number and the one above Tubercle articulates with vertebrae of same rib number
Exhalation Dysfunction Treatment
•Ribs 1 & 2 •Anterior & middle scalene à Rib 1 •Patient's hand on forehead and patient lifts head •Posterior scalene à Rib 2 •Patient's hand on forehead with head rotated 30 degrees away from the dysfunctional rib, patient lifts head •Ribs 3-5 •Pec minor •Patient's hand on or above the forehead, physician's hand on elbow, patient pushes elbow to opposite hip •Ribs 6-8 •Serratus anterior •Patient's shoulder flexed to 90 degrees and pushes elbow toward ceiling •Ribs 9-10 •Latissimus dorsi •Patient's arm is aBducted and pushes to same hip in coronal plane •Ribs 11-12 •Quadratus lumborum Patient is prone, physician lifts ASIS toward ceiling, while pushing ribs 11 or 12 medial and caudad
Rib Motion Ribs 1-5 move primarily in a Ribs 6-10 move primarily in a Ribs 11-12 move primarily in a What axis does each move along
•Ribs exhibit coupled motion of both pump and bucket handle (except 11 & 12 since they are not connected to the sternum): •Ribs 1-5 move primarily in a pump handle motion •Anterior and superior in inhalation •Monitor midline •Movement along the transverse axis •Ribs 6-10 move primarily in a bucket handle motion •Lateral and superior in inhalation •Monitor mid-axillary •Movement along the AP axis •Ribs 11-12 move primarily in a caliper (widening) motion •Posterior and lateral in inhalation •Monitor posteriorly •Movement on the vertical axis
Inhalation Rib Somatic Dysfunctions Remember: We find the area of restriction and name the dysfunction for the freedom of motion
•Screen for area restricted in motion, then name it for what it likes to do •Example: The left middle ribs (7-9) are not falling with exhalation •Convert the restriction to what they like to do -> They don't like to exhale, they like to inhale •Name the dysfunction -> Left Ribs 7-9 Inhaled •Find the key rib (key lesion) -> Inhaled rib dysfunctions have lowest rib in group holding other ribs up •Except wider intercostal space below •Key rib -> Left Rib 9 *On inhalation, the key rib dysfunction is named for the same rib On exhalation, the dysfunction is named for the intercostal space above it (rib two is intercostal space 1)
Autonomic Nervous system: Sympathetic vs parasympathetic
•Sympathetic: during times of stress •Increase heart rate •Open bronchial tubes, minimize watery secretions •Minimize gastric secretions, halt peristalsis •Kidney: salt and water retention •Increase peripheral vascular resistance - autoregulation •Pupillary dilatation •Minimize sinus secretions •Parasympathetic: Nutrition and repair •Increase gastric secretions and peristalsis •Increase oral, nasal, and sinus secretions •Slow heart rate •Close bronchial tubes, increase watery secretion, increase ciliary cell ratio •Pupillary constriction (good for near vision)
Cranial Division of the Parasympathetic Nervous System •The oculomotor nerve (cranial nerve III) goes to the : and is involved in: The facial nerve (cranial nerve VII) innervates the : (2)
•The oculomotor nerve (cranial nerve III) goes to the ciliary ganglion. It is involved with pupillary constriction The facial nerve (cranial nerve VII) innervates the pterygopalatine ganglion and submandibular ganglion.
The superior and inferior vagal ganglia (jugular and nodose ganglia) exit the skull via the _________ ___________, which is located near the:
•The superior and inferior vagal ganglia (jugular and nodose ganglia) exit the skull via the jugular foramen, which is located near the occipito-atlantal junction
Vagus Nerve •The vagus exits the skull through the: *Vagus passes through ________ hiatus and innervates: (3) *Subject to compression by __ joint ________ *Sometimes after fixing the ___________, we observe improvements in gastrointestinal function that we attribute to release of pressure on the vagus
•The vagus exits the skull through the jugular foramen •The superior vagal ganglion is in/ partially in foramen -> •Head forward position -> tissues at jugular foramen can get compressed (yellow circles) and irritate vagus (increased secretions and peristalsis/diarrhea) •Vagus descends and sends off some local branches •Treatment of the upper cervical = taking pressure off of the vagus Vagus passes through esophageal hiatus to innervate esophagus, heart and lungs *Directly connected to diaphragm •Fixing the diaphragm = improvements in gastrointestinal function ( release of pressure on the vagus)
Sphenopalatine (Pterygopalatine) Ganglion Release
•Too many secretions: tone it down: If a person has excessive nasal and sinus secretions because the sphenopalatine ganglion is irritated, we put a finger on the ganglion and gently release it. •Too little secretions: fire it up: If a person has dry, inflamed nasal and sinus mucosa, we will artificially irritate the sphenopalatine ganglion to increase secretions to wash away any viruses or bacteria before the mucosal barrier is breached.
Muscle Energy Treatment - Inhaled Ribs 1 (2)-5 Key rib:
•Treatment Position •Ribs 1-5: Patient is on physician knee; then push down on key rib with exhalation and maintain position with inhalation for 3-5 seconds •Repeat 3-5 times, passive stretch and return to neutral. •Reassess •Key rib: Bottom rib of group
Muscle Energy Treatment - Inhaled Ribs 6-10
•Treatment Position •Ribs 6-10: Patient will sidebend toward the ipsilateral foot; while the physician pushes down on the key rib with exhalation in the midaxillary line, then hold position against inhalation •Repeat 3-5 times •Passive stretch, return to neutral, reassess
Type I vs Type II Dysfunction (block 1)
•Type I: Neutral SD (somatic dysfunction) •The vertebra is neutral (neither flexed nor extended) •Sidebending and Rotation occur in opposite directions •Frequently occur as group dysfunctions •Ex: T4-6 N SR,RL •Type II: Non-neutral SD •The vertebra is flexed or extended •Sidebending and rotation occur in the same direction *Rotation occurs before sidebending! •Frequently single segment dysfunctions •Ex: T2 F RR, SR
Rib Landmarks (5) Typical vs atypical ribs
•Typical Ribs •Have all five landmarks (head (has 1 or 2 facets to articulate with costal facets of vertebra), neck, tubercle (articulates with TP of same rib #), angle, and shaft) •Include ribs 3-10 (talking about rib head) •Atypical Ribs: do not have all 5 landmarks (all have 1 and/or 2 in them) •Rib 1: no angle •Rib 2: 2 tubercles (extra tuberosity (tubercle) on the shaft) •Rib 11 and 12: no tubercle or neck and do not attach to sternum The rib heads of 2-9 have 2 demifacets, Ribs 1, 10-12 have a single articular facet that articulates with the corresponding vertebra Because Rib 10 has a single articular facet, it is sometimes referred to as atypical
Sympathetic Innervation Mapping T5-T9 What plexus?
•Upper abdominal viscera (celiac plexus) •Right: Liver, gallbladder, duodenum, and head of the pancreas •Left: Stomach, spleen, and tail of the pancreas
Sidebending Method: Typical Vertebrae (C2-C7) •When you translate a vertebra to the right, you are testing ________ sidebending •When you translate a vertebra to the left (bottom row), you are testing ______ sidebending
•When you translate a vertebra to the right (top row), you are testing left sidebending •When you translate a vertebra to the left (bottom row), you are testing right sidebending •Remember, you are testing sidebending of the vertebra on the vertebra below
Where Parasympathetic Nerves are Vulnerable to Compression or Traction: (2)
•Where they exit the spinal column •Where they traverse ganglia (which have a relatively tight capsule covering)
Sacral Rocking
•With a woman in labor, both sympathetics and parasympathetics need to be functioning normally. Pressure of the baby in pelvis can suppress pelvic splanchnic nerve function. *Sacral rocking functions to both relieve hyperfiring and stimulate nerves that have been suppressed, depending on specific conditions
Muscle Energy of Typical Vertebra: Ex. C3 F RrSr
●Finger of right hand monitors at C3 ○If you diagnosed using the rotation method, place your monitoring finger posterior to the articular pillar ○If you diagnosed using the sidebending method, place your monitoring finger lateral to the articular pillar ●Position head to barrier in 3 planes (E RlSl) ○Rotation method: Patient rotates head against thumb ○Sidebending method: Patient sidebends head against palm ●Instruct the patient to relax ●Move them into the new barrier ●Repeat 3-5x for 3-5 seconds ●Passive stretch and return to neutral ●Reassess
