OMM Spring 2019 Practical II + Review

Steps of lumbar spine diagnosis - type I and II

*Step 1*: Screen to the area of dysfunction using the sweep a. Stand to the side of the patient and sweep the spinous processes using the finger pads of one hand. b. Palpate for changes in the A-P curves, looking for gaps in the spinous processes that are not uniform. c. As you sweep, you may also encounter the following: lateral curves (scoliosis), rotations of single or multiple vertebrae, tissue texture changes, etc. d. Utilize both hands to sweep the paraspinal musculature for tissue texture changes *Step 2*: Determine Rotation by the Posterior Transverse Process: -Once you identify area(s) of dysfunction with the sweep, evaluate the position and motion of the transverse process with both *static palpation and motion testing* in *neutral* (sitting up straight), *flexed* (seated and bent forward with shoulders still above hips; ask patient to slump), and *extended* (seated and bent backwards with shoulders still above hips; ask patient to "stick their belly forward") a. While maintaining gentle pressure on the transverse processes the physician will see how the vertebra moves (either becoming more symmetric or asymmetric) as the patient goes in and out of the position of neutral into flexion and extension. b. The physician will corroborate the restricted motion by pushing on the transverse process with the thumb. If it does not move anteriorly as much as the other side, then it is considered posterior. *Step 3*: Diagnostic Interpretation

Upper cervicals - AA (C1 on C2) and C2 (C2 on C3) HVLA treatment

-*If AA and C2 are opposite rotations, can combine HVLA treatment by reversing the AA rotation and treating C2 at the same time. Don't forget to treat the flexion/extension component of C2 in this case*. Example - if AA is rotated left and C2 is FRrSr, you treat C2 using HVLA from the left side so as to reverse the AA rotation and treat C2 at the same time. -place lateral part of index finger on posterior articular pillar of vertebrae. -your finger acts as a fulcrum and to assists in monitoring the dysfunction. -sidebend first - *sidebending is much more slight* -flex or extend to that level -lastly, rotate to the barrier, so that the diagnostic formula is partially reversed. Since sidebending was so slight, rotation is not going to go further than the patient's pec or breast (line from nose to pec). *Ask if the patient has any pain in this barrier. If so, no thrust* -the thrust is quick, crisp, PURELY ROTATIONAL, and controlled -re-check

General explanation of LP/TL/iliac crest high treatments

-*Patient lies on the opposite side of the Roll or Shift, relatively close to the edge of the table, facing the physician, who is standing with thigh against the table at the level of the patient's arm.* -Isolate from the upper body by rotating the upper body towards the ceiling until motion is palpated at the vertebral level: *L5 for the L/P Roll and T12 for the T/L Shift* -Isolate from the lower body by *flexing the hip that is closer to the ceiling until motion is palpated at the vertebral level*: -L5 for the L/P Roll (top foot may be placed at popliteal fossa) -T12 for the T/L Shift (top leg may stay hanging off the table) -While stabilizing the upper body with one arm, *rotate the pelvis towards the physician with the other arm* until a barrier is reached. -To the hip closest to the ceiling, add a side-bending vector force that opposes the iliac crest height diagnosis to a barrier either towards the patient's feet or towards the patient's opposite shoulder. -Ask if there is pain after reaching the barriers (the hip flexion and pelvis rotation steps). -Have the patient breathe in and out. At the end of exhalation, a combined vector force is applied with further rotation of the pelvis toward the physician and side-bending towards the patient's feet or towards the patient's opposite shoulder (as appropriate to correct iliac crest height diagnosis). S.D. can be addressed with these techniques: a. HV/LA b. LV/MA c. ME three times to a 4th barrier d. Combination of ME with either LV/MA or HV/LA

Diagnosis of thoracic inlet

-*before diagnosis - push shoulders down to help open stuff up* -rotation: place fingers just below medial clavicle (costoclavicular space) to contact the anterior-most aspect of the first rib. You want to be as medial as posible. Assess which rib is more posterior (more compressible towards the table - can visualize and/or palpate). Example - if left 1st rib is more anterior and less compressible towards the table, the diagnosis is rotated right, meaning *T1 is rotated right.* -sidebending: place thumbs just anterior to the transverse process of T1 (just anterior to the external auditory meatus). Move tissue out of the way until you feel the first rib. Assess which first rib is more superior and which is more inferior. You can try static palpation or dynamic palpation by pushing inferiorly towards the feet. Sidebending of the thoracic inlet corresponds with the more inferior first rib. Example - if the left 1st rib is more superior and less compressible towards the feet, then the diagnosis is a left superior rib or sidebent right, meaning *T1 is sidebent right*

Thoracic inlet ME treatment

-*patient's hands resting on abdomen*. Push inferiorly on the shoulders to even them side to side on the table -to treat sidebending: push inferiorly on shoulder on the side of the elevated 1st rib. Place fingers under the armpit and pull superiorly. Ask the patient to *"press into both of my hands"*. Follow the steps of ME (bring to next barriers on both sides, etc.). -to treat rotation: place hand on posterior aspect of shoulder on the side of the rotation or the more posterior 1st rib. Apply an anterior force. Place the other hand on the anterior aspect of the shoulder on the side of the more anterior first rib (the side opposite the rotation). Apply posterior force. Ask the patient to *"press into both of my hands"*. Follow the steps of ME. -*recheck*

Trapezius pinch

-*physician is sitting* -hands are placed in a 'lobster claw' position grasping the trapezius muscles bilaterally. -the hands may be moved medially or laterally along the bulk of the muscle applying gradual pressure between the thumb and other four fingers. -when the physician encounters an area of restriction within the muscle they apply a steady force until a softening is appreciated. -treatment is completed when the entire length of the muscle is without restrictions. -re-check AA diagnosis.

Hyoid bone myofascial release treatment (2)

-*treat with your dominant hand* -indirect: take hyoid bone in the direction that it moves easier and hold until release (or 15-20 seconds). -direct: take hyoid bone in direction that it is restricted and hold until release (or 15-20 seconds)

Naming lumbar somatic dysfunctions

-1 - *determine rotation*: the rotation will be noted by the side of the posterior transverse process (e.g. transverse process of L4 is posterior on the right = L4 rotated right) -2 - *determine whether the SD is flexed, extended, or neutral*: a) flexed (type II) SDs: if a vertebra is rotated to the right and flexed, the posterior transverse process will be (1) most prominent when the lumbar spine is extended, (2) less prominent when the lumbar spine is neutral, (3) least prominent or symmetric when the lumbar spine is flexed. (e.g. diagnosis = L4FRrSr = L4 flexed, rotated right, sidebent right) b) extended (type II) SDs: if a vertebra is rotated to the right and extended, the posterior transverse process will be (1) most prominent when the lumbar spine is flexed, (2) less prominent when the lumbar spine is neutral, (3) least prominent or symmetric when the lumbar spine is extended. (e.g. diagnosis = L4ERrSr = L4 extended, rotated right, sidebent right) c) neutral (type I) SDs: if two or more vertebra are rotated to the same side and neutral, the posterior transverse process will be prominent when the lumbar spine is flexed, extended, AND neutral. (e.g. L1-4NSlRr = L1-4 neutral, sidebent left, rotated right) -3 - *assume sidebending*: a) principle 1 = if the rotation of two or more vertebrae are to one side, then the sidebending is to the opposite side (e.g. transverse processes of L1-4 are posterior on the right = L1-4 rotated right and sidebent left) b) principle 2 = if the rotation of one vertebra is to one side, then the sidebending is to the same side (e.g. transverse process of L4 is posterior on the right = L4 rotated right and sidebent right)

Treatment of anterior thoracic tenderpoints 1-6 with strain/counterstrain

-Anterior TP T1-6: a. Physician stands behind and slumps the patient into them for support and to facilitate relaxation. Physician's abdomen supports patient's back b. With patient slumped, make a "C" shape with your hand and place it at the cervicothoracic junction. Apply gentle pressure through the spine (downward compression) c. Position of ease is accomplished primarily with flexion and minor rotation and/or sidebending of the thorax.

Treatment of anterior thoracic tenderpoint 12 with strain/counterstrain

-Anterior TP T12: a. Physician stands on same side as the tender point. b. With the patient supine, place patient's legs on physician's knee, flexing the patient at the hip. The physician rotates and sidebends the patient around the tender point by bringing the knees and feet towards the tender point. c. Fine-tuning is accomplished with further sidebending and rotation of the pelvis towards the tender point.

Anterior thoracic tenderpoints

-Anterior thoracic tender points: a. 1-6 midline: located on the sternum, with some degree of sidedness; corresponds to costal (rib) level. b. 12 bilateral: AT12 is at the midaxillary line on the inner iliac crest. -often correlates with flexed SDs

Neck landmarks that may be helpful (not emphasized in lab)

-C1 = between angle of the mandible & the mastoid -C2 = at the angle of the mandible -C3 = hyoid -C4 = superior thyroid cartilage -C5 = inferior thyroid cartilage -C6 = level of the cricoid cartilage -C7 = vertebral prominens

Treatment of the TL fascia

-Example: T/L shift Left and ICH Left (CCP) 1. Patient lies on the right, relatively close to the edge of the table, facing the physician, who is standing with thigh against the table at the level of the patient's arm. 2. Isolate from the upper body by rotating the upper body towards the ceiling until motion is palpated at the T12 spinous process. 3. Switch monitoring hands, so that the caudad hand is free. To do this, have the patient make genie arms so you can loop your cranial hand through their arms. Your hands are "teepee'd" over each other at L5. This puts the caudal forearm exactly where it needs to go. You're hunched over the patient's body and leaning over the table, which is ideal. It's helpful to have your thigh against the patient's shoulder and your legs staggered. 4. Isolate from the lower body by flexing the hip that is closer to the ceiling until motion is palpated at the T12 spinous process (top leg may stay hanging off the table). 5. While stabilizing the upper body with one arm, *rotate the pelvis towards the physician* with the other arm until a barrier is reached. 6. To the hip closest to the ceiling, add a sidebending vector force that opposes the iliac crest height diagnosis to a barrier towards the patient's feet. Either towards their shoulder if that's the low crest (lift crest up) or towards their foot if that's the high crest (bring crest down) 7. Ask if there is pain after reaching the barriers in steps 5 and 6. 8. Have the patient breathe in and out. At the end of exhalation, a combined vector force is applied with further rotation of the pelvis toward the physician and side-bending towards the patient's feet (as would be appropriate to correct iliac crest height diagnosis). -S.D. can be addressed with these techniques: 1. HV/LA - if doing HVLA, make sure you push all the way to the barrier and then do your thrust at the end of exhalation. 2. LV/MA 3. ME three times to a 4th barrier 4. Combination of ME with either LV/MA or HV/LA

CCP

-LP roll = right -iliac crest = high on left -TL shift = left

Treatment of upper pole L5 (UPL5) posterior lumbar tenderpoint with strain/counterstrain

-Patient is prone. -Stand on the same side as tender point. -Place the patient's thigh on your knee, grasp the leg below the knee and induce external rotation. -ADduct the patient's leg. This should occur as the leg gently rolls down and into external rotation on the physician's leg. -Push gently down on the lower leg to flex the pelvis.

Treatment of high iliac crest

-Perform thoracolumbar soft tissue-prone *on the high iliac crest side* to ease tissues holding up the iliac crest. 1. Patient is placed in a prone position. 2. Physician stands on the opposite side being treated. 3. With the hand closest to the patient's feet, the physician grasps the ASIS on the opposite side of the table. 4. On the same side of the body that the first hand was placed, the physician places their other hand (hand closest to patient's head) over the paraspinal muscles adjacent to the lumbar spine. 5. Each hand does a different motion at separate times: a. The hand controlling the pelvis at the ASIS moves first to gently pull the pelvis off the table toward the physician. b. At the end of that motion, and with the other hand, the physician starts applying gentle pressure into the paraspinal muscles through the heel of that hand as the pelvis is slowly returned to the table. c. This alternating motion is referred to as a "kneading" motion. d. This motion is repeated while monitoring for a response from the tissues. e. The hand over the paraspinal muscles can be moved along the length of these muscles: down to the base of the sacrum and as far up as the lower half of the thoracic vertebrae. 6. Completion of the treatment will be noted by a softening of the tissues or increased range of motion. 7. Recheck the iliac crest heights supine for symmetry.

TMJ diagnosis - ROM testing and palpation

-ROM Testing: Approximate how wide the mouth can open. If normal, should permit 3-4 fingers lined vertically. This can be used as an objective finding at the end of your treatment to determine if you have helped increase the patient's ROM -palpate the TMJ as the patient opens and closes mouth, checking for clicks or crepitus. Clicking or popping occurs due to movement of disc, laxity of ligaments, or both. The location of the click/pop does not indicate the side of the TMJ dysfunction. -observe chin deviation while patient opens mouth slowly -*chin points to the side of TMJ restriction/muscle tightness* -if the motion of the jaw deviates to both sides making an "S", treat the side with the largest deviation (the tighter side).

Treatment of posterior lumbar 1-5 spinous process *and* posterior lumbar 1-3 transverse process tenderpoints with strain/counterstrain

-Stand on *OPPOSITE side* of tender point. -Shorten the tissues around the tender point: -Extend to spinal level -Physician grabs hold of the patient's ASIS -Physician pulls the ASIS toward themselves in order to sidebend and rotate the pelvis towards the tender point. -*May need to place pillow under patient's chest to achieve extension.*

Treatment of anterior lumbar 2, 3, and 4 tenderpoints with strain/counterstrain

-Stand on *OPPOSITE side* of tender point. i.. Place both of the patient's calves on physician's knee WITHOUT crossing the ankles. ii. Flex hips to spinal level (L2, L3, L4). iii. Rotate the pelvis *away* from the tender point by bringing the knees away from the tender point (towards the physician). iv. Sidebend away from the tender point by bringing the ankles away from the tender point (towards the physician).

Treatment of anterior lumbar 5 tenderpoint with strain/counterstrain

-Stand on *SAME side* as tender point. i. Place both of the patient's feet on physician's leg and CROSS the ankles with the ipsilateral leg (of the tenderpoint) below the contralateral leg, allowing the knees to separate. ii. Flex hips to approximately 90⁰. iii. Rotate the pelvis toward the tender point (by bringing the ipsilateral knee towards the physician). iv. Sidebend away from the tender point (by pushing ipsilateral knee inferiorly, away from the tenderpoint which also takes the ankles toward the midline) - i.e. Dr pushes ankles away from them

Treatment of anterior lumbar 1 tenderpoint with strain/counterstrain

-Stand on *SAME side* as tender point. i. Place both of the patient's legs over physician's thigh WITHOUT crossing the ankles. (Physician's knees should be in the patient's popliteal fossa) ii. Flex patient to L1 spinal level. iii. Rotate the pelvis *towards* the tender point by bringing the knees towards the tender point. iv. Sidebend towards the tender point by bringing the ankles towards the tender point. v. If needed, fine tune with the hand on patient's ankles by pushing towards the table (inducing flexion of the lumbar spine). This will further flex the pelvis.

Body areas that affect the thoracic inlet

-T-spine (Types I/II, paraspinal tightness, and tenderpoints) -respiratory ribs, posterior ribs, and anterior/posterior rib tenderpoints -trapezius muscle tightness or strain -UE restrictions in motion -OA issues -AA issues -C2-C7 issues -head/neck tenderpoints

Thoracic spine landmarks for diagnosis

-T1 can be found using cervical flexion to distinguish C7 vs. T1. -On a patient sitting up straight, or standing up straight, the following scapular landmarks correspond with the general area of certain vertebrae: a. Below vertebra prominens (C7) = T1 SP b. Spine of scapula = T3 SP. To find spine of scapula, slap patient on the back/shoulder and you will find it every time. c. Inferior angle of scapula = T7 SP, overlies rib 7 and points to rib 8 d. Attachment of rib 12 = T12 SP

Treatment of posterior thoracic tenderpoint T1-12 *transverse* process with strain/counterstrain

-T1-12 transverse process (bilateral - lateral aspect): a. Patient prone with *same side arm abducted* next to patient's head. b. Turn patient's head *towards* the side of the tender point for patient comfort. Like smelling armpit. c. Physician stands on OPPOSITE side of tender point, grasps the axilla, and pulls it towards self and cephalad, thereby extending, rotating towards and sidebending away. -Mnemonic = "travel" for transverse - stand on opposite side of tenderpoint

Treatment of posterior thoracic tenderpoint T1-4 spinous process with strain/counterstrain

-T1-4 spinous process (bilateral - i.e. spinous process tenderpoints are lateralized): a. Patient prone with *arms hanging off table.* b. Turn patient's head away from the side of the tender point for patient comfort. c. *Physician stands on SAME side of tender point*, grasps opposite shoulder and pulls it towards the tender point and *caudally* (towards the patient's feet), thereby *extending, rotating and sidebending away*.

Mnemonics for posterior thoracic spinous process tender point treatments

-T1-4: "hands toward the floor" (arms off table) -T5-9: "tummy time" (hands on stomach) -T10-12: "hands on the PELVis" (hands on ASIS)

Treatment of posterior thoracic tenderpoint T10-12 spinous process with strain/counterstrain

-T10-12 spinous process (bilateral): a. Patient prone with hands under ASISs. b. Turn patient's head away from the side of the tender point for patient comfort. c. *Physician stands on SAME side of tender point*, grasps opposite shoulder and pulls it towards the tender point and *caudally* (towards the patient's feet), thereby *extending, rotating and sidebending away*.

Treatment of posterior thoracic tenderpoint T5-9 spinous process with strain/counterstrain

-T5-9 spinous process (bilateral): a. Patient prone with hands under abdomen. b. Turn patient's head away from the side of the tender point for patient comfort. c. *Physician stands on SAME side of tender point*, grasps opposite shoulder and pulls it towards the tender point and *caudally* (towards the patient's feet), thereby *extending, rotating and sidebending away*.

Psoas tenderpoint diagnosis and treatment with strain/counterstrain

-To diagnose: go medial - 2/3 from ASIS to midline and press deep posteriorly into tissue. -To treat: patient is supine and physician is on same side as tenderpoint. Patient's knees are flexed with ankles resting on physician's thigh (NOT crossed). Flex the hips and sidebend the hips towards the side of the tenderpoint by *bringing the ankles towards the physician*. Follow counterstrain steps.

Iliacus tenderpoint diagnosis and treatment with strain/counterstrain

-To diagnose: go medial, 1/3 from ASIS to midline. Press down and push laterally to find tenderpoint. -To treat: Stand on same side of TP. Patient supine. Flex patient's hip and knees and place lower legs/ankles on your thigh. Cross the patient's ankles with their ipsilateral ankle on the bottom to create ABduction and external rotation of hips. Let knees relax to side. Fine tune w flexion/ rotation of hip. Follow counterstrain steps.

Naming the OA diagnosis

-a - Flexion/Extension Component: The SD is named for where translation becomes more symmetric. Example: translates equally to each side in flexion = OA is a Flexed SD -b - Sidebending Component: diagnosis of the sidebending component is opposite the direction the OA translates easier. Example: Translates easier to right = OA is sidebent left -c - The rotational component is NOT TESTED; it is INFERRED to be OPPOSITE to the diagnosed sidebending component. Example: The OA translates easier to the right in extension = OA is flexed, sidebent left, rotated right -*the hand you're using in ease of translation is the direction of sidebending* -*rotation diagnosis is the same as ease of translation*

OA ME treatment using de-translation

-a - reverse the flexion/extension component and then translate the head towards the restriction (treat the dysfunction where you found it). -b - treat with muscle energy by asking the patient to push their head gently to the right or left against your hand. Physician resists isometrically for three seconds and brings it to the next barrier. Repeat three times to a fourth barrier. -c - re-check OA diagnosis with translation in flexion and extension. -d - picture shows the treatment for an OA that is FSlRr. Treatment: Extension and de-translation to the left while patient isometrically resists physician's force. *Note: This is a very slight motion* -*ALWAYS RECHECK*

Medical reasoning for thoracic inlet and components

-congestion -edema Anatomic = T1, 1st ribs/costal cartilages, and superior manubrium Functional = T1-4, ribs 1 and 2/costal cartilages, and manubrium

TMJ diagnosis - visual inspection

-evaluate the alignment of the upper vs. lower front incisor teeth noting deviation of lower teeth.

Way to remember treatment for type II SDs

-for Type II dysfunctions, hand is placed on the shoulder, because the patient has "two" shoulders.

Thoracic inlet HVLA treatment when rotation and sidebending to same side - treatment of sidebending component

-four steps: Roll, Place, Scoop, Fine Tune -*treat from a standing position*. -roll the head away to expose the cervico-thoracic junction. -setup and treatment of SIDEBENDING component: -place the lateral aspect of the DIP joint of the index or middle finger *on top* of the costo-transverse articulation then firm pressure is applied in an inferior (towards the patient's feet) and medial direction. You will notice a "buckling" motion of the neck around your hand. *It helps to have the same leg forward (power stance) as the hand you're using to induce sidebending* -scoop the head back until the nose is midline and the thumb is on the chin. Be careful not to roll the head back or lose the pressure on the costo-transverse articulation. -fine tune by slightly flexing or extending, rotating or sidebending the neck and head to achieve the localization of the barrier. -HVLA thrust: the physician's hand on the patient's chin thrusts towards the opposite ASIS with a corkscrew thrust while the hand underneath the head follows by sweeping the head in the opposite direction. -if you did not get the desired results with one thrust re-adjust and attempt again, before you lay the head down. You may attempt a thrust up to three times. -DO NOT Recheck at this time.

Alternative treatment position for omohyoid tenderpoint

-indications = rotator cuff injury, frozen shoulder, or patient is unable to ABduct their shoulder due to discomfort or lack of ROM -treatment - passively shrug the patient's shoulder. -passively sidebend and rotate the patient's head towards their scapula -push patient's hyoid bone towards the side of the TP. Hold for 90 seconds or a release is felt. Return to neutral and recheck.

Omohyoid TP and treatment

-located at any of the following: on the muscle as it originates on the suprascapular notch, medial to the notch of the scapula (between clavicle and spine of scapula), or as it courses over the 1st rib. -treatment - approximate scapula to neck by resting ipsilateral (??) forearm on patient's forehead. Patient must have their forearm completely relaxed and resting on the physician's forearm. -passively sidebend and rotate the patient's head towards their scapula -push patient's hyoid bone towards the side of the TP. Hold for 90 seconds or a release is felt. Return to neutral and recheck.

TMJ TP and treatment

-location - directly over the TMJ (basically in front of the tragus) -treatment - Same as masseter TP: -patient is supine. Physician pushes the patient's jaw slightly open and toward the side of the TP to produce lateral glide. -physician also applies a counterforce to the upper lateral aspect of the head on the TP side with the monitoring hand and/or uses their abdomen to stabilize the patient's head -follow CS steps

Posterior C4-C8 TP (bilateral) and treatment - *before doing these, ask if you get dizzy when looking up*

-location - inferolateral surface of the spinous process *above* the level. (e.g. posterior C4 tenderpoint is on the inferolateral surface of the spinous process of C3) -treatment - extension of neck with rotation and sidebending away for fine tuning. -note: posterior C8 also has two points located at the posterior surface of the transverse processes of C7. Treatment position is the same as above.

Masseter TP and treatment

-location - tenderpoint is in the superficial and deep fibers of the masseter muscle. The palpating finger presses *posteriorly* on the cheek towards the anterior border of the ascending ramus of the mandible -treatment - patient is supine. Physician pushes the patient's jaw slightly open and *toward the side of the TP to produce lateral glide*. -physician also applies a counterforce to the upper lateral aspect of the head on the TP side with the monitoring hand and/or uses their abdomen to stabilize the patient's head -follow CS steps

Anterior C8 TP and treatment

-location: Clavicular head (pushing laterally within the jugular notch). -treatment: same as for C2-6 (*a lot of flexion (at C8)* of the neck with the rotation and sidebending away) to bring mastoid to sternum. -follow the steps of counterstrain. -re-check AA diagnosis

Anterior C1 TP and treatment

-location: High on the posterior edge of the ramus of the mandible. -treatment: Rotate the head away, almost to ninety degrees.

Inion TP and treatment

-location: One inch below the inion, in the midline of the inferior nuchal line. Diagnose supine -treatment: Marked flexion of the head on the neck, with the greatest flexion applied right under the skull. This is accomplished by tilting the chin towards the chest.

Posterior C3 TP (bilateral) and treatment

-location: inferolateral surface of the spinous process of C2 -treatment: flexion of neck to 45 degrees with rotation and sidebending away from the side of the spinous process that is tender

Posterior C1 TP (bilateral) and treatment - *before doing these, ask if you get dizzy when looking up*

-location: on the inferior nuchal line midway between inion and mastoid. -treatment: Extension of head (put mild pressure high on occiput without compressing spine, just extending). With fine tuning of slight rotation and sidebending away

Posterior C2 TP (bilateral) and treatment - *before doing these, ask if you get dizzy when looking up*

-location: superolateral surfaces of the spinous process of C2 -treatment: Same as Posterior C1 TP. Extension of head (put mild pressure high on occiput without compressing spine, just extending). With fine tuning of slight rotation and sidebending away.

Anterior C7 TP and treatment

-location: ¾-1 inch lateral to the clavicular head on the superior surface of the clavicle. -treatment: *full flexion of neck* by pushing on the middle of the back of the neck (rather than flexing through the head or upper neck). *Sidebend towards and rotate away.* (trying to bring mastoid to clavicle) -NOTE: the goal of this treatment is to shorten the SCM muscle. -follow the steps of counterstrain. -re-check AA diagnosis.

Anterior C2-6 TPs

-locations - anterior surface of the tips of the transverse processes at the same level (use line of ear hole to guide you to the transverse process) -treatment - flexion of the neck with the rotation and sidebending away

Naming C2-C7 (lower cervicals) diagnosis

-named for ease of motion: -flexion/extension component: The somatic dysfunction is named for where translation becomes more symmetric. Example: C3 translates equally to each side in flexion = C3 is a flexed SD. -sidebending component: diagnosis of the sidebending component is opposite the direction the cervical segment translates easier. Example: C3 translates easier to the right = C3 is sidebent left. -the rotational component is NOT TESTED; it is INFERRED to be the SAME as the diagnosed sidebending component. Example: C3 translates easier to the right in extension = C3 is flexed, sidebent left, rotated left or C3 FRLSL -test in both flexion and extension (movement down to specific cervical segment by flexing or extending until motion felt at specific segment)

C2-C7 (lower cervicals) ME treatment

-need to use pincer grasp -flex or extend until motion is palpated at the segment to be treated. If flexed, extend. If extended, flex. Lower vertebrae take more motion for flexion or extension. *For flexion, bring chin down to chest (don't lift whole head off table)* -physician introduces sidebending and rotation opposite the somatic dysfunction *until motion is palpated at the segment to be treated*. -patient exerts a 3-second isometric contraction towards neutral position. -physician engages new barriers in extension or flexion, sidebending, and rotation. -repeat 3 times to a fourth barrier. -recheck cervical dysfunction

TMJ ME treatment

-patient is supine. -with the mouth slightly open, the physician takes the patient's *mandible away from the direction of the chin deviation and into the barrier to stretch the tight side*. -the physician applies a counterforce to the upper lateral aspect of the patient's head on the opposite side with the other hand and/or abdomen to stabilize the head (may use pillow). -the patient GENTLY pushes into the physician's hand while they resist isometrically. -repeat to the 4th barrier and re-check

AA diagnosis

-patient supine with the physician *STANDING* at head of table. -place one hand on each side of the head and lift head to *fully flex the cervical spine*, thus completely isolating the AA joint. -rotate the head to the right and then to the left, without bringing it out of flexion. -using the nose as a "goniometer," note to which side it rotates further. -*diagnosis = rotation only*.

TMJ myofascial release (MFR) treatment

-perform this technique if ME did not resolve the dysfunction, if both sides are restricted, or if your patient's jaw deviates in an "S" shape. -warn your patient not to bite down on your fingers. -treatment - patient supine. Physician places gloved thumbs on superior aspect of lower molars. Physician pulls posterior jaw towards patient's feet and lifts anteriorly towards the ceiling. Hold until a gentle release is felt or for 20-30 seconds.

Cervical stretching

-physician is sitting -if the patient presents with an elevated or tight musculature on the left side: -the physician is seated at the head of the table with their right forearm crossed under the patient's head and with their hand placed on the superior aspect of the patient's left shoulder. -the physician then places their other hand on the left side of the patient's head. -the physician then pushes the left shoulder down towards the feet until a painless, gentle pull is felt in the patient's head. -the physician holds this position until a release is appreciated (feels like the distance between the shoulder and head has increased. -re-check AA diagnosis.

OA diagnosis

-place one hand on each side of the head with palms cupping the ears. Fingers should be on the occiput. -assess translation of the occiput in flexion and extension *using the middle finger (works best)*. You can induce flexion/extension by just pushing or pulling on the head (head should stay straight as it moves side to side - *patient's ears do not go towards their shoulders*). -OA = always opposite rotation/sidebending.

Type II SD - characteristics

-position of spine = flexed or extended -coupled sidebending/rotation = same side -number of vertebrae = a single vertebral unit -muscles involved = short restrictors -causes = trauma, exceeding the normal range of motion

Type I SD - characteristics

-position of spine = neutral -coupled sidebending/rotation = opposite sides -number of vertebrae = several (typically >3) -muscles involved = long restrictors -causes = postural, chronic, leg standing preference

C2-C7 ST treatment

-posterior cervical soft tissue -the patient is supine and the physician is standing at the patient's side with one hand on the patient's forehead just above the eyebrows. -with the finger pads of their other hand, the physician rhythmically stretches and compresses the soft tissues between the spinous and articular processes of the cervical vertebrae while sidebending, rotating, and extending the cervical spine. This can be accomplished by bringing the finger pads laterally and anterior. The hand on the forehead acts as stabilizing point only, but is not so tight on the forehead as to not allow for some small motion to occur. -this is applied bilaterally from the occipito-atlantal region to the first thoracic vertebra. -recheck cervical diagnosis

CCP of thoracic inlet

-rotated right -sidebent right -elevated left first rib

Thoracic inlet HVLA treatment when rotation and sidebending to same side - treatment of rotation component

-setup and treatment of ROTATIONAL component: -*treat from a standing position*. -roll the head away to expose the cervico-thoracic junction. -place the lateral aspect of the DIP joint of the index or middle finger *behind* the costo-transverse articulation and then firm pressure is applied in an inferior and rotational direction (towards the patient's opposite shoulder). You will notice a "buckling" motion of the neck around your hand. *It helps to have the same leg forward (power stance) as the hand you're using to induce sidebending* -scoop the head back until the nose is midline and the thumb is on the chin. -fine tune by slightly flexing or extending, rotating or sidebending the neck and head to achieve the localization of the barrier. -HVLA thrust: the physician's hand on patient's chin uses a pure rotational thrust towards the opposite shoulder while the hand underneath the head follows by sweeping the head in the opposite direction. If you did not get the desired results with one thrust re-adjust and attempt again, before you lay the head down. You may attempt a thrust up to three times -DO NOT RECHECK the inlet until you have completed BOTH the sidebending and rotation treatments. -when finished, recheck both the sidebending and the rotational components.

Treatment of lower pole L5 (LPL5) posterior lumbar tenderpoint with strain/counterstrain

-similar to piriformis tenderpoint treatment (except in LPL5, you don't need to go past 90 and you also ADduct instead of ABduct) -Sit on SAME side of tender point. -Shorten the tissues around the tender point by moving the leg on affected side off the table. i. Flex hip and knee to approximately 90° ii. Slightly ADduct the leg by pushing the knee towards the table

OA soft tissue treatment

-suboccipital tension release -with the patient supine and the physician seated at the head of the table, the physician places their finger pads together under the suboccipital area (occipito-atlantal junction). -with their finger pads, the physician directs pressure anteriorly and superiorly with a force comparable to the weight of the head. -treatment is continued until the tissues release as evident by the head falling into the physician's palms. Repeat as needed. -this may be applied up to the nuchal ridge where muscles are commonly tight due to stress. -*ALWAYS RECHECK*

Levator scapulae TP and treatment

-superior medial portion of the scapula -patient is supine. -the shoulder is flexed to about 30° *(barely lift arm up)*. This usually means the elbow is not above the level of the chest. -the elbow is fully flexed and kept close alongside the body. -compress along the axis of the humerus. -fine tune as needed. -re-check AA diagnosis.

Medical reasoning for any of this neck stuff (cervicals, TMJ, or hyoid)

-swallowing difficulties -neck pain -nausea

Upper trapezius TP and treatment

-tenderpoint is located anywhere along the upper part of the trapezius muscle -patient is supine. -drape patient's arm over physician's monitoring arm. -sidebend and rotate patient's head *towards* the tender point. -fine tune by rotating the head away. -follow the steps of counterstrain. -*passively return to neutral* and re-check AA diagnosis -alternative treatment position = Indications: patient is unable to ABduct their shoulder due to discomfort or lack of range of motion. Sidebend and rotate patient's head towards the tender point. Passively shrug the patient's shoulder using the patient's elbow. You can maintain pressure on the patient's elbow to help maintain the treatment position. Follow the steps of counterstrain. Re-check AA diagnosis

Summary of steps for the OA diagnosis

-test translation in flexion and extension. -wherever the OA moves symmetrically, name the flexion/extension component of the SD. -bring the OA where it is NOT symmetric and investigate the sidebending component. -infer rotation (opposite to the sidebending) after you have your sidebending diagnosis. -Example: Translates equally to each side in flexion = OA is flexed -Example: Translates easier to the right than the left in extension: = OA is flexed SlRr -*ALWAYS RECHECK*

AA diagnosis naming

-the AA is named for the ease of motion. -e.g. patient's head rotates more to the left than to the right (has restricted rotation to the right). Diagnosis: AA Rotated Left

AA ME treatment

-the patient is supine with the physician *STANDING* at the head of table. -with the cervical spine in full flexion, take the AA to the rotational barrier (if their diagnosis is rotated left, rotate them right). -gently hold the patient in that position and treat with muscle energy by asking the patient to gently rotate ("turn") their head back to the midline. The physician resists the patient's force isometrically and then rotates to the next barrier. Repeat three times to the fourth barrier. -re-check in full flexion. -picture shows the treatment for an AA that is rotated left. Treatment for this diagnoiss = full flexion of the cervical spine and rotation of the head into the restricted barrier while patient isometrically resists physician's force.

Supine fingerpad technique of translation for lower cervicals diagnosis

-the patient is supine with the physician sitting at the head of table. -patient's head is in physician's hands. -with your finger pads on the articular pillars (facets), do a general sweep upward on the cervical spine to assess for asymmetry, tissue texture change, and/or tenderness. This will clue you in on where to look for a specific cervical segmental dysfunction. You may also feel soft tissue or bony abnormalities that need to be addressed further. -with the *finger pads of your middle fingers* placed on the posterior articular pillars (NOT the transverse processes) at a specific cervical segment, translate by pushing *antero-medially* on each side while *applying gentle pressure with the opposite hand on the side of the head to sidebend the neck and head around the fingers that are pushing the articular pillars*. Translation tests SIDEBENDING to the opposite side. -a bump/tightness to one side means you're sidebent to the opposite side

Supine pincer grasp

-the physician grasps the articular pillars using their thumb and index or middle fingers (pincer grasp). Physician's hand/palm supports the occiput. -the motion of the cervical segment can be diagnosed using the pincer grasp in two ways: i Translate at the head: (1) The hand on top of the patient's head translates the head left and right in both flexion and extension. (2) The listening hand on the articular pillars determines the direction in which the cervical segment translates easier. (3) The segment is diagnosed by the way in which it moves more easily. ii Translate at the listening hand: (1) The hand on top of the patient's head induces flexion and extension down to the cervical segment being diagnosed. (2) The listening hand (pincer grasp) on the articular pillars translates the cervical segment left and right in both flexion and extension. (3) The segment is diagnosed by the way in which it moves more easily. -hands oppose each other - left middle finger pad pushes right and right hand pushes left

Diagnosis of hyoid bone

-to find the hyoid bone, place the lateral aspect of your index finger on the tip of the chin and slide posteriorly until you feel the front of the hyoid bone. Slide the tip of your index finger and thumb laterally to the edge of the hyoid bone. -you should not feel crepitus. If you do, you are too low and are on the cartilaginous rings of the trachea. If you feel a pulsation, you are too lateral and are on the carotid arteries. -grasp the hyoid with finger and thumb and check motion left-to-right and right-to-left, assessing ease of motion.

AA soft tissue treatments

-trapezius pinch -cervical stretching

Thoracic inlet HVLA treatment when rotation and sidebending are NOT to the same side

-treat from a *standing position*. -roll the head away to expose the cervico-thoracic junction. -place the lateral aspect of the DIP joint of the index or middle finger on *top* of the costo-transverse articulation of the elevated first rib, placing firm pressure in an inferior and medial direction. *It helps to have the same leg forward (power stance) as the hand you're using to induce sidebending* -with the hand that is under the head, 'scoop' the head back until the nose is midline and the thumb is on the chin. -a firm barrier is realized between both hands. -fine tune by slightly flexing or extending (depending on the diagnosis of T1) and rotating or sidebending the neck and head to achieve the localization of a firm barrier between both hands. -HVLA thrust: the physician's hand on the patient's chin thrusts towards the opposite lower ribcage with a corkscrew thrust while the hand underneath the head follows by sweeping the head in the opposite direction. If you did not get the desired results with one thrust re-adjust and attempt again, before you lay the head down. You may attempt a thrust up to three times. -because of the angulation of the thrust, the rotational component is addressed as well as the elevated rib. -recheck the sidebending and rotational components.

C3-7 (lower cervicals) HVLA treatment

-treatment position for C4 FSrRr: C4 ESlRr OR ESrRl -due to the coupled motions of the cervical spine vertebra, the physician can pick either side of the somatic dysfunction to partially reverse the diagnostic formula. -place lateral part of index finger on posterior articular pillar of vertebrae. -your finger acts as a fulcrum and to assists in monitoring the dysfunction. -sidebend first -flex or extend to that level (*don't lose the sidebending*). *Keep nose midline* -lastly, rotate to the barrier, so that the diagnostic formula is partially reversed. *Ask if the patient has any pain in this barrier. If so, no thrust* -the thrust is quick, crisp, PURELY ROTATIONAL, and controlled -re-check -*you can pick either half of the SD to reverse due to the coupled nature of the cervical vertebrae*

Treatment guidelines for type I and II SDs

-type II SDs are treated before type I -you may find a type II hidden within a type I SD -when flexing/extending the spine during a treatment, you can check for motion by placing a finger on the spinous process at the level of the dysfunction and a finger on the spinous process of the vertebra below. Palpate either for separation or approximation of fingers -when rotating the spine during a treatment, you palpate the spinous process at the level of the dysfunction for motion in the opposite direction of the side of the rotation (i.e. when rotating the patient to the left, the spinous process of the level of the dysfunction will move to the right)

Finding T12

-use last rib in midaxillary line = rib 11. This gives you T11. Then go 1 vertebra down.

What are the 3 principles of physiologic motion?

1. *Principle I*: When the thoracic and lumbar spine are in a *neutral position* (not flexed or extended), the coupled motions of sidebending and rotation for a *group* of vertebrae occur in *opposite directions* (with rotation occurring toward the convexity and sidebending toward the concavity). a. Motion is caused by *long restrictor muscles*. 2. *Principle II*: When the thoracic and lumbar spines are *flexed or extended* (non-neutral position), the coupled motions of sidebending and rotation in a *single* vertebral unit occur in the *same direction*. a. Motion is caused by *short restrictor muscles*. 3. *Principle III*: Motion introduced into one plane of spinal motion will *inhibit or modify* spinal motion in *all other planes*. a. When the spine is flexed, the amount of rotation and sidebending is decreased or when the spine is sidebent, the amount of flexion/extension and rotation is decreased.

Diagnosis of thoracic type I and type II SDs

1. *spinous process sweep*: Stand to the side of the patient and sweep the spinous processes using the finger pads of one hand from the cervical spine to the lumbar spine. Palpate for changes in the A-P curves, looking for gaps in the spinous processes that are not uniform. As you sweep, you may also encounter the following: Lateral curves (scoliosis), Rotations of single or multiple vertebrae, and Tissue texture changes (in general: hot, cool, tense, boggy, dry, ropy, moist, atrophy, spasm, etc.) 2. *paraspinal sweep*: The physician will use the Whole Hand Principle to "sweep" the paraspinal areas, looking for: changes in the anterior to posterior (A-P) curves, lateral curves (scoliosis), rotations of single or multiple vertebrae, tissue texture changes (in general). The physician will be able to isolate the regions with the most prominent tissue texture changes. The paraspinal sweep can be done one handed or two handed: One Handed: The physician uses one hand to gently palpate the back from the top of the thoracic spine to the bottom of the lumbar spine. Part of the hand will be on one side of the spinous processes and the other part on the other side of the spinous processes. OR Two Handed: The physician can use one hand on each side of the spinous processes and gently sweep from the top of the thoracic spine to the bottom of the lumbar spine. The spinous process sweep and paraspinal sweep will usually correlate as to the place of significant somatic dysfunction. 3. *Localize the specific vertebral level using landmarks* 4. *Localize the specific transverse processes by using the rule of threes* 5. *Finalize the diagnosis by assessing for either type I or type II SDs*

Diagnosis of iliac crest heights in supine position

1. Place fingers on *top* of the iliac crests at the level of the *mid axillary line* on both sides. 2. With the dominant eye in the midline of patient, determine which crest is more superior. 3. Diagnosis is named for which crest is superior. 4. CCP: Crest is high on left = IC high on left NOTE: If excess tissue is a problem, start by placing fingers just inferior to iliac crests bilaterally. Push excess soft tissue out of the way by pushing superiorly and medially. When you contact the top of the iliac crest with your fingers push slightly inferiorly to ensure you are resting directly on top of the crests.

Diagnosis of T/L shift

1. Place hands laterally on lower portion of ribcage bilaterally. 2. Translate to one side by pushing directly on lower portion of ribcage towards the midline, return to neutral and repeat to opposite side. 3. Determine the side to which the tissues move more easily. 4. Diagnosis is named for the direction of *the ease of motion.* 5. CCP: TL shifts easier to the left = T/L shift left. NOTE: It is strongly suggested that you allow the tissues to return to a neutral position before moving them in the opposite direction. Moving the tissues too quickly makes it very difficult to distinguish fascial asymmetry. You will determine this by the feel of the tension in the tissues. If you are having a difficult time determining the diagnosis, try stabilizing the opposite iliac crest to minimize the movement of the tissues below (not pictured).

Diagnosis of LP roll

1. Place one hand behind ilium and roll the pelvis right. 2. Opposite hand may assist the roll by using ASIS of opposite side (put palm *flat on ASIS*). 3. Return tissues to neutral then reverse hand placement to assess roll to opposite side. 4. Assess the tissues based on the feel of the tension. 5. Diagnosis is named for the direction of the ease of motion. 6. CCP: L/P rolls easier to right = L/P roll right. NOTE: It is strongly suggested that you allow the tissues to return to a neutral position before moving them in the opposite direction. Moving the tissues too quickly makes it very difficult to distinguish fascial asymmetry. Pay close attention to induce mainly rotation and not translation.

ME treatment for thoracic spine type I SDs (full T-spine)

1. T5-10 NSlRr: The same principles for Type II SD treatment apply, but the formula is reversed accordingly. In this case T5-10 will be treated by taking the SD towards NSrRl. 2. Direct treatment position: Palpate at the apex (middle part of the curve) of the curve (spinous process of T7 or T8) *PRIOR to starting any motion in the treatment*. Ask patient to position right hand behind the neck (side of rotation) and left hand on the right elbow (side of sidebending). Physician reaches through patient's arms, grasping right upper arm. Sidebend patient to right (*away from their existing sidebending dysfunction*) until motion is felt at the apex, rotate patient to the left (*away from their existing rotation dysfunction*) until motion is felt and keep the spine neutral without flexion or extension (*shoulders above hips*). a. ME treatment: ask the patient to gently rotate back to the right for 3-5 seconds (the way they *want to go*). Repeat 3 times to a 4th barrier, *reaching new barriers in both sidebending and rotation each time while keeping the spine neutral without flexion/extension*.

Naming thoracic SDs

1. The SD is named according to the position of the vertebra. a. The diagnosis should be given in the following order: i. Vertebral Level (T7, T3-5, etc.). ii. Flexed, Extended, or Neutral. iii. Direction of Rotation and Sidebending (*rotation first for Type II's, sidebending first for Type I's*). iv. Example. T7 FRrSr , T11 ERlSl, T5-9 NSlRr. 2. Flexed Somatic Dysfunctions: a. If a transverse process is posterior while the patient is in the extended position and it then *becomes symmetric with the other transverse process in the flexed position, then it is a flexed SD* and, according to the 2nd principle, *it is rotated and sidebent towards the side of the posterior transverse process*. i. It is described in the medical record as FRrSr or FRlSl. The vertebral level is placed before the description of the vertebral position. 3. Extended Somatic Dysfunctions: a. If a transverse process is posterior while the patient is in the flexed position and it then *becomes symmetric with the other transverse process in the extended position, then it is an extended SD* and, according to the 2nd principle, *it is rotated and sidebent towards the side of the posterior transverse process*. i. It is described in the medical record as ERrSr or ERlSl. The vertebral level is placed before the description of the vertebral position. 4. Neutral Somatic Dysfunctions: a. If a group (typically 3 or more) of transverse processes are posterior on one side while the patient is in all three positions (neutral, flexed, and extended), it is a neutral SD and, according to the 1st principle, it is *rotated towards the side of the posterior transverse processes and sidebent to the opposite side*. i. It is described in the medical record as NSlRr or NSrRr. The vertebral levels are placed before the description of the vertebral position.

ME treatment position for type I SDs - seated - lumbar

1. Vertebra position: L1-4 is neutral, sidebent left, rotated right (L1-4 NSlRr). 2. To position the patient; have them take their hand on the *side of the rotation* and place it on their neck and grasp their elbow with the opposite hand (i.e. if NSlRr patient takes their right hand and places it on their neck and then grasps their elbow with the left hand). The hand that moves first (grasps the neck) is the rotation side. The hand that moves second (grasps the elbow) is the sidebend side. 3. Direct treatment position: palpating at the apex (*middle*) of the curve (spinous process of L2 or 3) for motion, sidebend patient to right until motion is felt at level (opposite their diagnosis), rotate patient to the left until motion is felt (opposite their diagnosis), and keep the spine without flexion or extension. *A handy way to sidebend patient - Dr stands a little taller (like on tippy toes), which will sidebend them a bit* 4. ME treatment: ask the patient to gently rotate back to the right for 3-5 seconds. Repeat 3 times to a 4th barrier, reaching new barriers in both sidebending and rotation each time. 5. Recheck the dysfunction in the position it was found. Type I dysfunctions are found in neutral, so they should be re-checked in neutral. *IMPORTANT: Shoulders should remain over hips to ensure proper sidebending of the spine (so don't super sidebend your patient!!!)*

ME treatment position for type II extended SDs - seated - lumbar

1. Vertebra position: L3 is extended, rotated right and sidebent right (L3 ERRSR). 2. To position the patient, have them take their hand on the side of the rotation and place it on the opposite shoulder (i.e. if ERlSl patient takes their left hand and places it on their right shoulder). This starts the rotation in the opposite direction engaging the direct barrier. 3. Direct treatment position: palpating at the spinous process for motion, flex patient until L3 moves, rotate patient to the left at L3 and side bend patient to the left at L3. 4. ME Treatment: ask the patient to gently rotate back to the right for 3-5 seconds. Repeat 3 times to a 4th barrier, reaching new barriers in flexion, sidebending and rotation each time. 5. Recheck the dysfunction in the position it was found. Extended dysfunctions are found in flexion, so they should be re-checked in flexion. The easy rule is, if it is found in flexion it is treated in flexion and it is re-checked in flexion (AKA extended SD). *IMPORTANT: Shoulders should remain over hips to ensure proper sidebending of the spine (so don't super sidebend your patient!!!)*

ME treatment position for type II flexed SDs (seated) - lumbar

1. Vertebra position: L3 is flexed, rotated right and sidebent right (L3 FRrSr). 2. To position the patient, have them take their hand on the side of the rotation and place it on the opposite shoulder (i.e. if FRlSl patient takes their left hand and places it on their right shoulder). This starts the rotation in the opposite direction engaging the direct barrier. Dr then puts their armpit on patient's hand. 3. Direct treatment position: palpating at the spinous process for motion, *extend patient until L3 moves*, *side bend patient to the left at L3*, and *rotate patient to the left at L3*. 4. ME Treatment: ask the patient to *gently* rotate back to the right for 3-5 seconds. Repeat 3 times to a 4th barrier, reaching new barriers in extension, sidebending and rotation each time. 5. Recheck the dysfunction in the position it was found. Flexed dysfunctions are found in extension, so they should be re-checked in extension. The easy rule is, if it is found in extension it is treated in extension and it is rechecked in extension (AKA flexed SD). *IMPORTANT: Shoulders should remain over hips to ensure proper sidebending of the spine (so don't super sidebend your patient!!!)*

ME treatment for thoracic spine type II SDs at T1-T4 (upper T-spine) in either flexion or extension

1. When diagnosing or treating T1-T4, the physician may use the patients head to localize motion. a. *Ask if patient complains of neck pain or neurologic symptoms*. If yes, do not use this treatment. Use the other one. b. Monitor level BEFORE setting up for treatment or else you may over rotate/sidebend/extend/flex beyond the level of the somatic dysfunction. -*in doing these treatments - KEEP SHOULDERS OVER HIPS* 2. For the treatment of T4 ERlSl: a. Stand behind the seated patient and grasp the patient's head with your right hand. b. Monitor the motion at T4 over the spinous process with your left hand while localizing force at T4. c. Flex, sidebend, and rotate the head to the right to engage these barriers at T4. d. Ask the patient to try and bring their head back toward their left shoulder using minimal force as you resist isometrically. Hold for 3 seconds. e. Upon relaxation, "take up the slack" to reengage the barrier in all 3 planes of motion (utilizing isometric ME protocol). f. Repeat for 3 cycles to a 4th barrier. 3. For the treatment of T4 FRlSl: a. Stand behind the seated patient and grasp the patient's head with your right hand. b. Monitor the motion at T4 over the spinous process with your left hand while localizing force at T4. c. Extend, sidebend, and rotate the head to the right to engage these barriers at T4. d. Ask the patient to try and bring his/her head back toward his/her left shoulder using minimal force as you resist isometrically. Hold for 3 seconds. e. Upon relaxation, "take up the slack" to reengage the barrier in all 3 planes of motion (utilizing isometric ME protocol). f. Repeat for 3 cycles to a 4th barrier.

Treatment of the LP fascia

Example: L/P rolls Right, ICH Left (CCP) 1. Patient lies on the left side (*opposite the side of the LP roll*), relatively close to the edge of the table, facing the physician, who is standing with thigh against the table at the level of the patient's arm. 2. Isolate from the upper body by rotating the upper body towards the ceiling until motion is palpated at the vertebral level at the L5 spinous process. Find the iliac crest and then go down one vertebra. 3. Switch monitoring hands, so that the caudad hand is free. To do this, have the patient make genie arms so you can loop your cranial hand through their arms. Your hands are "teepee'd" over each other at L5. This puts the caudal forearm exactly where it needs to go. You're hunched over the patient's body and leaning over the table, which is ideal. It's helpful to have your thigh against the patient's shoulder and your legs staggered. 4. Stretch their lower leg so it is fully extended and straight in line with their body. Isolate from the lower body by flexing the hip that is closer to the ceiling until motion is palpated at the L5 spinous process (top foot may be placed at popliteal fossa). 5. While stabilizing the upper body with one arm, *rotate the pelvis towards the physician* with the caudal arm until a barrier is reached. Keep hands teepee'd. 6. To the hip closest to the ceiling, add a side-bending vector force that opposes the iliac crest height diagnosis to a barrier towards the patient's opposite shoulder. Either towards their shoulder if that's the low crest (lift crest up) or towards their foot if that's the high crest (bring crest down) 7. Ask if there is pain after reaching the barriers in steps 5 and 6. 8. Have the patient breathe in and out. At the end of exhalation, a combined vector force is applied with further rotation of the pelvis toward the physician and side-bending towards the patient's opposite shoulder (as would be appropriate to correct iliac crest height diagnosis). -S.D. can be addressed with these techniques: 1. HV/LA 2. LV/MA 3. ME three times to a 4th barrier 4. Combination of ME with either LV/MA or HV/LA -with ME, don't remove the arm from the buttcheek to take patient to the next barrier. Just push with your forearm to bring them to the next barrier.

Way to remember treatment for type I SDs

Memory Aid: for Type I dysfunctions, hand is placed on the neck, because the patient has "one" neck.

Anterior lumbar tenderpoint locations

Tender point locations (evaluated supine). a. 1— medial aspect of ASIS b. 2— medial aspect of AIIS c. 3— lateral aspect of the AIIS d. 4— inferior aspect of the AIIS e. 5— on the anterior, superior aspect of the pubic ramus just lateral to the pubic symphysis

How do you find the anterior inferior iliac spine (AIIS)?

With your hands on the ASIS (as above) palpate caudally and slightly medially until you find the next bony prominence. This will be smaller, deeper, and less prominent than the ASIS. You may have the patient try to raise their leg towards the ceiling with the knees straight to contract the rectus femoris muscle which attaches to this landmark. Stand on your dominant eye side. Bilateral structure.

Posterior thoracic tenderpoints

a. 1-12 spinous processes bilateral: on the *inferior or infero-lateral aspect* of the tip of the spinous process bilaterally. b. 1-12 transverse processes bilateral: at the *lateral aspect of the transverse process bilaterally*.

Posterior lumbar tenderpoint locations

a. 1-5 (Spinous Process) - On the inferior or infero-lateral aspect of the tip of the spinous process. b. 1-3 (Transverse Process) - At the lateral aspect of the transverse process. c. Upper Pole L5 (UPL5) - On the superior medial surface of the PSIS. d. Lower Pole L5 (LPL5) - Just under 1 inch straight below the UPL5.

Muscles used in thoracic inlet ME treatment

a. Pectoralis major (protracts scapula) b. Pectoralis minor (protracts scapula) c. Middle Trapezius (retracts scapula) d. Lower Trapezius (retracts scapula) e. Rhomboids (retracts scapula) f. Upper trapezius (elevates scapula) g. Levator scapula (elevates scapula) h. Latissimus Dorsi (depresses scapula)

ME treatment for thoracic spine type II SDs (full T-spine) in either flexion or extension

a. Physician monitors the spinous process at the level of the vertebra being treated (in this case, T7). Monitor for the motion of the spinous process, not just the soft tissues around that region. b. After placing monitoring hand, patient places the hand on the same side of the rotation on their opposite shoulder. If done without monitoring, initial hand placement patient may rotate past area of localization with this motion alone! c. All three planes of motion need to be addressed: i. Extended SDs: Patent is asked to "slump forward" to help induce flexion for the treatment of extended somatic dysfunctions (top photo). Physician should monitor for separation of the spinous process in relation to the one above. Physician puts armpit on patient's hand ii Flexed SDs: Patient is asked to "arch their back" to help induce extension for the treatment of flexed somatic dysfunctions (bottom photo). Physician should monitor for approximation of the spinous process in relation to the one below. iii Sidebending Component: Physician induces translation through their axilla to induce sidebending until motion is felt at the spinous process. iv Rotation Component: Physician adds rotation towards self until the spinous process in question moves away from the physician. d. The goal is to isolate to a specific level *while keeping the shoulders above the hips* so that the patient is not off balance and can stay relatively relaxed.

Rule of Threes for thoracic spine diagnosis

a. T1-3: TP at the same level of SP b. T4-6: TP halfway between SP at same level and one level above c. T7-9: TP at SP one level above d. T10: TP at SP one level above e. T11: TP at halfway between SP at same level and one level above f. T12: TP at the same level of SP -The transverse process is located one finger breadth lateral to spinous process in the thoracic spine. Place a thumb on the tip of each transverse process.

Documentation of the thoracic inlet

a. T1RrSr with an elevated left 1st rib b. T1RlSl with an elevated right 1st rib c. T1RrSl with an elevated right 1st rib d. T1RlSr with an elevated left 1st rib

Double arm thrust for type II thoracic SDs

a. The patient is supine. Stand opposite the side of the vertebral rotation. b. Position arms by crossing them across patient's chest, making sure the arm on the side of the SD is cephalad (elbows are stacked on top of each other). Do a pain check: Add gentle compression into the table and confirm with patient that the compression does not cause pain anywhere in the body. c. Roll patient towards you and sweep the spine with the whole hand to find the posterior transverse process. Place your thenar eminence on the posterior transverse process. d. Roll patient back onto your thenar eminence. e. Formation of Fulcrum: i. Localize the forces of the patient's weight combined with yours to the SD at your thenar eminence by creating a vector force from your abdomen through the patient's elbows to the SD. *Move patient's elbows superiorly and inferiorly until you feel the most pressure on your thenar eminence* ii Use pillows between the patient's chest and elbows and/or above the elbows to further localize the fulcrum as well as protect your chest wall. f. *Side-bend the patient's trunk toward you* until you feel slight motion at the involved segment (very little sidebending is needed). g. Localize to either flexion or extension: i. If the SD is flexed, let the spine straighten slightly to induce extension of the spine at the level of the SD without losing the natural kyphotic curve of the rest of the thoracic spine. ii If the SD is extended, the head and thorax should be flexed to level of the involved segment. h. Add gentle compression through the head to shorten the spine and encourage relaxation of ligaments and muscles. *it's helpful to use your elbow crook and connect that hand to the hand on the transverse process* i. While maintaining flexion or extension, ask the patient to take a deep breath in, exhale, and relax. j. Following exhalation, apply an HVLA/LVMA thrust with your epigastrium towards the involved transverse process. k. This thrust is felt at your thenar eminence and an articulation may be palpated &/or heard.