Practical #2
WHAT TO WORRY ABOUT when doing counterstrain
!!!!!!Without identification of a tender point you cannot do counterstrain!!!!! -MUST Clearly and discretely identify the tender point -Pick the most significant tender point in the region -Maintain light contact with the tender point -throughout treatment to facilitate recheck
guiding a patient when force is applied
"Gently side bend to your left (or right)." If the patient used too much force: "Now give me ½ that much (or 2/3 or ¾)." If the patient used too little force: "Give me double that force please"
where is listening hand in treatment?
'listening hand' may be on the ipsilateral or contralateral rib angle depending upon the sidebending ease. MUST BE ON RIB ANGLE
Left Unilateral Extended Sacrum
(+) Sphinx Test
Bilateral Sacral Extension
(+) spring test at sacral base (-) spring test at ILA's
Treatment - Bilaterally Flexed Sacrum
(-) spring test at sacral sulci (+) spring test at sacral ILA
Left Unilateral Flexed Sacrum
+ Spring test on Left ILA
Right on Left Torsion Backward Torsion
+ spring test at R sulcus, + sphinx test (ease on extension although sacrum should flex)
internal versus external rotation for treatment L3 ER(L)S(L)
-(extend ipsilateral leg if internal, contralateral if it is external rotation) - side-bend to the left both times - internal- rotates pelvis right (ipsilateral) -external- rotate pelvis right (contralateral leg)
Dysfunction: Ankle
-Anterior/posterior talus Most common: anterior/plantar flexed talus Treatment Direct -Seated or supine-- dorsiflex foot until talus reaches edge of resistance, have patient plantarflex against resistance Treatment Indirect Seated or supine plantarflex foot to ease, balance all motions possible, use breath as activating force
Diagnosis Review & Treatment -Carpal bones
-Articulatory with traction -Any carpal dysfunction -Place hands perpendicular to pts, one on each side of their wrist -Squeeze palms together and use clockwise and couterclockwise motion, or figure-of-eight carrying dysfunction gently through the barrier(s) -Recheck
reassessment
-CHECK SAME POINT YOU TREATED - maintain contact during return to neutral -reduce tenderness to about 70%, if not check for more points, or may need to repeat again -Warn patients about treatment reaction
How does it all fit together in patient care?
-Correct Diagnosis Use history and physical exam -Correct Structural Diagnosis Screen, Scan, Segmental Diagnosis -Management OMM/Medications/Home Exercises -Follow-up
ways to treat anterior ribs
-Counterstrain Intercostal tender points -Muscle Energy Pump handle ribs -Anterior Rib Fulcrum [new technique] -Functional Methods Anterior rib release Same contact as muscle energy, but treating in the directions of ease
REASONING BEHIND FPR
-Decreased gain on the muscle spindle gamma loop the spindle becomes unloaded ceasing the firing of Ia fiber discharges to the motor neuron controlling extrafusal muscle fiber and cause relaxation.
Upper Extremity: Segmental Definition
-Determined during scan -Joint named for position of ease or motion of ease -Finding is relative to contralateral UE Ex. Sternoclavicular Joint Superior Clavicle at Sternoclavicular Joint Superior Glide at Sternoclavicular Joint Note: Segmental definition in upper extremity is similar to segmental definition in the axial spine
patient directions when counterforce applied
-Direct the patient to hold this isometric contraction for 3-5 seconds -Against continuing physician resistance -Then direct the patient to relax -Reposition into resistance in side bending & rotation -patient tries to sidebend the other direction
T4-T12 FRSleft:
-Doc on opposite side of vertebral rotation -Pt. cross arms-opposite (left) on top -Roll pt. into flexion with cephalad hand -Fulcrum (caudad/right) thenar eminence posterior to left transverse process -Roll over fulcrum at stuck facet to extend at dysfunction while -Flexion is maintained while head/neck is used to introduce sidebending (right) down to the dysfunctional segment -Thrust thru elbows straight down into fulcrum (medial to thenar eminence) causing extension Basically just turn into the segment
Characteristics of good FPR
-Easily applied -Non-traumatic -Effective and efficient -Relief of tenderness and restores function -Can be repeated -Other methods of treatment can be applied immediately afterward
flexed or neutral dysfunction
-Flexed or neutral dysfunction only -Patient is prone and physician stands on the side of posterior transverse process. -Caudad hand, pisiform region inferior to transverse process, fingers pointing cephalad -Cephalad hand, thenar eminence on opposite inferior transverse process fingers pointing toward patient's feet -Pt. inhale/exhale to localize forces -Thrust is anterior and rotatory engaging both flexion and rotation
Screen TART AND STAR- what generic questions might u ask?
-How are the TART/STAR criteria useful at this level of diagnosis? -General Impression -Is there a problem? -What regions exhibit a problem? Gait /A-P /Lateral TART -tissue texture abnormalities -asymmetries -restriction to motion -tenderness or STAR -sensitivity changes instead of tenderness tissue texture & motion tests
Name some characteristics of FPR.
-Indirect technique -Accurate DIAGNOSIS is essential -Placement of the spine in a NEUTRAL position in order to disengage\idle facets (flatten the axial spine) -Superficial Muscles: ABNORMAL MUSCLE TENSION -Deep Muscles/ Segment: based on segmental definition -ACTIVATING FORCE (compression, torsion, or traction)
Mechanics of Internal Rotation of the Hip
-Internal rotation of the right leg (pelvis rotation left) -Results in rotation of the lumbar spine to move towards the leg that is internally rotated (Which is the right side in this example)
Talus assessment
-Locate the medial and lateral malleoli -Now, move medially and anteriorly to the midline of the foot. -Palpate the rounded prominence. This is the head of the talus -Input rotary motion between the talus and calcaneus and compare motion bilaterally
tender points
-Located in tendinous attachments, bellies of muscle, other myofacial tissues -Typically discrete, small tense, edematous -Non-radiating -Identify most-significant tender point in a group -Palpate with finger pad -Use your structural exam to guide you -Significant tender points result from the patient attempting to obtain a comfortable posture to alleviate the functional distress -Tender points tend to be at the apex or the focal point of a the concavity. -Forward bent=anterior -Backward bent=posterior -Sidebent right=tender points to left -Sidebent left=tender point to right of spine -Tender points are frequently 180 degrees around the body from the point of presenting pain
2 caveats about ME
-ME of the lumbar spine is similar to that of the thoracic spine but we increase the magnitude of motion applied in order to localize at the more distally located somatic dysfunction. -Soft tissue treatment to the area of the segment should be done after ME treatment.
Mobilization with Impulse
-Make an accurate structural diagnosis -Engage resistance in as many planes of motion as necessary for appropriate localization -The impulse force is vectoral. -Direction - into at least one restriction (Fryette's 3rd Principle), -Duration & amplitude- split second, less than 1/8 - 1/4 inch of motion -Patient relaxation is key -Deliver the vectoral impulse as the patient exhales. This allows for a minimum of force. -Recheck
A-A Motion!! motions*
-NO JOINT - 1/2 of cervical range of motion -Total rotation ROM- 70 degrees- 35 each side ==Hyperflexion locks out facets of C2-7 & OA- only AA rotates* ==Can get 45 degrees if other cervicals not fully locked out -Some F/E- 17 degrees ==F=forward & down E= backward & down ==Small amount side bending-involuntary wobble effect ==Anterior arch slides superior/inferior on dens ==Facets always engaged-No physiologic neutral
Characteristics of FPR! passive? active? indirect? direct? soft tissue? dysfunction?
-Passive -Indirect -Facilitating force compression/torsion -May be used to treat soft tissue or or specific joint dysfunction -Decreased gain on the muscle spindle gamma loop the spindle becomes unloaded ceasing the firing of Ia fiber discharges to the motor neuron controlling extrafusal muscle fiber and cause relaxation.
O-A Lateral Translation- with testing
-Passive movement -Lateral translation of head while remaining parallel to sagittal plane of trunk -Quality of motion -Observe distance from midline in flex, ext, and neutral -Normal translation of the head = 3-4" per side 1" trans.=arc of 1-2 degrees of opp. SB -Patient supine-head at end of table -Doc stand at head of table- feet apart, knees bent, elbows level with pt. head, hands close to body -Support head with finger pads of both hands, under center of gravity -Translate head keeping it parallel to trunk- move head by shifting body side to side -Estimate amount of translation- =Translation = opposite side bending -Test in neutral and varied degrees of flexion and extension -Describe findings in restriction then name diagnosis by position (ease). O-A Lateral Translation Test: Translation Resistance Left or Right with the Head in Flexion or Extension => Diagnosis (FSleftRright, ESleftRright, etc.) Example: ESRRL (ESRleft)
Exhalation Dysfunction Rib 1-10 - Bucket Handle
-Patient Supine, -Doctor contacts inferior aspect of rib; finger pads contact via interspace below the rib (mid-axillary line) -Monitors and supports inhalation phase. -Sidebending patient away from the dysfunctional rib -Respiration is activating force, patient takes a deep breath, doctor follows the rib with inhalation and resists exhalation -Reposition (increase sidebending) -REPEAT (3-5 times) -RECHECK Engaging resistance is augmented by sidebending of the axial spine away.
Inhalation Dysfunction Rib 1-10 - Pump Handle:
-Patient Supine, -Flex the spine to dysfunctional segment, supported for doctor -Add sibebending toward the rib -Doctor contacts superior aspect of rib monitor anteriorly -Respiration is activating force, patient takes a deep breath, doctor resists inhalation and follows the rib more with exhalation -Reposition (increase flexion and sidebending) -REPEAT (3-5 times) RECHECK Engaging resistance is augmented by flexion & sidebending of the axial spine.
Segmental Definition
-Patient cross arms in the front -Find the rib angle -Place your arm over the patient's shoulder and introduce side bending to the right and then to the left -Stand on the side of side bending ease and introduce rotation and note which way is ease -Ask the patient to drop his or her shoulders and then straighten up -Ask the patient to take a deep breath in and exhale. Under your finger is there decreased tension with inhalation or exhalation. Does the rib angle move smoothly with inhalation or exhalation. (up with inhalation and down with exhalation
Right on Left Torsion
-Patient in lateral recumbent position with axis DOWN -Physician uses caudad hand to flex the knees until motion is felt at the lumbosacral junction -Physician pulls patient's arm closest to the table to rotate patient while monitoring L5 -Patient should be on back -Patient's bottom leg is extended until force is felt to localize to the right sacral base. -Patient's top leg is dropped of the table in front of other leg. -ME Treatment: patient pushes leg (ankle) toward the ceiling while physician restricts motion -Patient relaxes and the leg is allowed to drop further to floor; readjust other elements, as needed. -Perform 3-4 x's
Exhalation Dysfunction Ribs 11-12
-Patient prone ARMS ABOVE HEAD, Doctor on opposite side of the table -Legs pulled toward doctor to side bend, ipsilateral arm above head -Doctor grasps ASIS and rotates pelvis posteriorly -Doctor places hand laterally over involved rib -Patient takes a deep breath, Doctor pushes laterally on the rib (gapping joint) -Hold breath & localization 3-5 seconds EVERYONE RELAX!! -Reposition (increase traction on rib and increase posterior rotation of the pelvis) -REPEAT (3-5 times) -RECHECK
Inhalation Dysfunction Ribs 11 & 12
-Patient prone ARMS AT SIDE, Doctor on opposite side of the table -Legs pulled toward doctor to side bend, ipsilateral arm at side of body -Doctor grasps ASIS and rotates pelvis posteriorly -Doctor places hand proximally over involved rib (medial fulcrum) -Patient takes a deep breath, exhales; Doctor pushes laterally on the rib (gapping joint) -Hold 3-5 seconds -EVERYONE RELAX!! -Reposition (traction on the lower ribs and posterior rotation of the innominate) -REPEAT (3-5 times) RECHECK
hand position for physician
-Place operating forearm and hand on the shoulder of side bending resistance -Create elbow pressure down on the patient's resistance-side shoulder and induce sidebending into restriction -Elbow pressure forward and backward will create either left or right rotations into resistance. -physican force is arrow
What are two defining characteristics of FPR?
-Place the patient in the position "EASE" for the segment - Activating force cuts down treatment time to 3-5 seconds.
Treatment of 1st Rib: Inhalation
-Position: Pt places hand on forehead: looking straight ahead -Counterforce: Doctor resists motion at 1st rib anteriorly -Contraction: Patient asked to raise head off the table
Dysfunction: Interosseous
-Proximal or distal restriction identified by testing motion while palpating both proximal fibular head and lateral malleolus Treatment Indirect -while holding proximal and distal fibula, balance ease within interosseus membrane and soft tissue, use breath as activating force
Treating the Lumbar Spine Using a Long Lever L3 FR(L)S(L)
-Pt prone -Pillow under abdomen to flatten lordosis -Doc seated at left side of table facing pt's head with right lateral thigh beside table -Monitor the left transverse process with finger of left hand -Drop pt's flexed left knee and thigh off table, over doc's right thigh -Grasp pt's knee with right hand and flex hip -Adduct the knee toward the table -Some compression may be added through the pt's knee -Hold for about 3-5 seconds and slowly return to neutral -Recheck
Treatment of Thoracic Superficial Muscles
-Pt seated -Monitor hypertonic area with listening hand -Doc places left forearm on pt's left shoulder and behind neck -Pt instructed to "sit up straight" to flatten kyphosis -Add compressive through to listening hand -Sidebend and rotate the pt toward the listening hand -Hold 3-5 seconds -Return to neutral slowly -Recheck
C2-7 HVLA-Side Bending
-Pt supine on table with doc standing at head of table Support head on side of ease with palm of hand (broad contact) -Contact articular pillar of segment on side of SB restriction with MCP joint of index finger -SB to restriction over MCP and translate to restriction -Flex or extend to segment -Rotate head to side of ease to lock out segment above -Adjust F/E, SB, and rotation to localize -Translational thrust through articular pillar with index finger -Recheck
The Diagnostic Process - Scan Seated Flexion Test
-Pt. Seated & feet flat on the floor -Operator - thumbs on inferior slope of PSISs -Pt. Forward bends with arms between the knees One PSIS moves further than the other More Cephalad or Ventral This is the Side of the Sacroilial Dysfunction
AA HVLA-Rotation
-Pt. supine-doc standing at head of table -Cradle head in hands -Contact right posterior arch of atlas with MCP joint of index finger on side of rotation -Flex head to about 30-45 degrees to take out motion of the other vertebrae -Rotate to restriction -Slightly adjust SB & F/E as needed for localization -Thrust-rotational ==forearm aligned with vector of force ==generated through forearm into wrist and MCP -The support hand does not participate in force generation during the thrust -Recheck
A-A Rotation Test C1 is pure rotation
-Rotation with Maximum flexion!! -Pt. supine-stand at head of table -Cradle occiput in both hands -Flex to lock out C3-7 -Rotate to both sides-compare Possible flexion and extension
C2-3 HVLA-Rotation
-Stand at head of table -Support head with hands -Index fingers on B/L articular pillars -Slightly sidebend segment towards EASE -Rotate to RESTRICTION -Flex to segment * -Slightly extend at & above segment* -Quick thrust thru both hands with rotational movement, support hand does not thrust -Recheck
C3-C7 articular facets
-Superior facets facing backward upward and medial -This requires rotation and sidebending to the same side
Trapezius
-Tender point is either anterior or posterior along superior edge of trapezius muscle. -abduct arm, suspend from fingers and flex elbow. -Fine tuning anterior or posterior depending on point location
return to neutral
-The patient must remain passive during the return to neutral -TELL THEM TO NOT MOVE -make sure if patient tenses, STOP TREATMENT you tell them to chill before you finish! - note first couple degrees are important and try to not excite proprioceptive mechanisms
alternative way to apply force- bear hug
-The physician's axilla could be used on the shoulder instead. -If you have the patient cross his arms, this looks like your diagnostic procedure. It also increases patient stabilization.
supine cervical sidebending technique
-Use translation L & R to create side bending into resistance --Left translation creates right sidebending and vice versa -Add rotation into resistance -Add flexion/extension into resistance
Articulations of each thoracic vertebra
-With vertebra above and below -With the vertebral disc of adjecent vertebral segments -Articulates with adjacent ribs
"joint play" deals with
-articulation of joint architecture tension and laxity of ligaments and tendons
Unyielding Counterforce
-counterforce is toward resistance for the diagnosed segment -The amount of force will determine how big of an area you engage for the treatment (more force for a larger involved area) -The resistance the operator applies determines how much force the patient generates.
Levator Scapulae 2.0
-extend the arm slightly -head rotated to tender side, -inferior traction while holding the wrist -extremity in internal rotation
Anterior C1
-find behind ascending ramus of mandible half way between mastoid process and inferior angle of the jaw -treat: rotate head 90 degrees away, apply side-bending away to reduce sensitivity- apply caudal force on contralateral parietal aspect of cranium- do not apply extension and do not maintin position if discomfort increases
Rib 1a: the pose of despair
-leg same side as tender point -patient drapes arm over that side -side bend head to that side with flexion-tune tender point -pay put legs on the table and flexed to induce more effect
tissue response
-relax muscles -inc temp response -pulsation under finger tips
7. Cervicals 8. Rest of Upper Extremity
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hand placement for functional methods with arm movement
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SCAN (__________ response to motion)
1 tissue 1 motion- immediate response to motion- looking for points of increased resistance
Sequencing technique**
1) diagnose accurately 2) patient must be comfortable 3) position to restrictive barrier 4) use release-enhancing maneuvers *BREATHING, springing, jaw clenching 5) deliver thrust once relaxed 6) reasses
Plan
1) diagnostics 2) OMT, medication 3) patient education etc.
assessment
1) medical diagnosis 2) regions of somatic dysfunction
important motions 1,2,3,4
1) rotation- decreased lower 2) lateral flexion- limited upper freer lower extension 3) 2nd least: flexion, more in lower TPs separate- facets up and forward (open) 4) extension: least: more in lower, limited by approx- more in lower- TP's are close to one another facets down and back (closed)
Rule of 3's
1-3 SP= TP 4-6 SP =1/2 below TP 7-9 SP= 1 below TP 10=7-9 11=4-6 12=1-3
Lower Half of the Body Diagnosis & Treatment Sequence
1. Hip restrictors 2. Pubic bone dysfunction 3. Superior innominate shear ("innom. upslip") 4. Lumbar dysfunction (esp. L5 or, less often L4) 5. Sacral dysfunction 6. Innominate dysfunctions (other than upslip) 7. Iliopsoas (including thoraco-lumbar junction, approx. T11-L2) 8. Other Lower Extremity Dysfunction
Diagnosis: Fascial restriction of interosseous membrane
1. Stabilize the humerus - done by patient position. 2. Make contact with the proximal radius - prox. hand; distal hand - hand shake. 3. Use the motions available across the joint to enhance ease. --Supination/pronation, Med/lat & Ant/post translation, flexion/extension, compression/traction. 4. 'Stacking' sequentially; Use respiratory ease; Eventual 'Smooth Torsion Arc'
1st Rib
1. Stand on side of dysfunction. 2. Place caudad hand over 1st rib - monitor. 3. Bend patient's elbow, 4. Flex/abduct arm to maximum ease under monitoring fingers. 5. Compress at elbow with force directed toward rib 6.Internally rotate arm against physicians' caudad forearm 7.Hold 3 seconds 8.Abduct followed by circumduction back to anatomical position-maintain compression 9.Release and re-evaluate
Screen the upper extremities -
2 Tissue Texture 2 Motion Tests Scan using Position and Motion comparing bilaterally: 1. Sternoclavicular 4. Elbow 2. Acromioclavicular 5. Wrist 3. Glenohumeral 6. Hand Segmentally Definition Based on motions at each unique joint Name in ease of position and motion
dysfunction
2 texture, 2 motion
screen req (HOW ______ you encounter resistance)
2 tissue 2 motion- how soon do I encounter resistance
functional technique describe defining characteristic
3 Rotary Motion Asymmetries 3 Translation Motion Asymmetries Anterior/posterior rotation Left/right translation Cephalad/Caudad translation Respiration Asymmetry COMPLETE MOTOR ASYMMETRY (imp vocab word)- All motions are involved when there is somatic dysfunction present *note above and below!! inhlation and exhalation
sacral motion all axes
3 Transverse axes Superior, Middle, and Inferior 2 Oblique axes Right and Left 1 Longitudinal axis 1 Anterior-posterior axis
Muscle phys review: alpha gamma motor neuron review
= A disturbance of MS function initiates a series of events beginning with stimulation to mechanoreceptors and nociceptors, resulting in afferent neural activity... = The final common pathway is the alpha motor neuron that stimulates the muscle fiber to contract, and through the gamma system, the muscle spindle to adapt, resulting in alteration in muscle tone. = Chronic dysfunction feeds the afferent loop, more nociception and abnormal mechanoreceptor information, perpetuating ongoing aberrant muscle tone.Disturbance Results in alteration, adaptation Interruption and reprogramming of the vicious cycle contribute to improvement of overall muscle tone and balance. What this means= JOB SECURITY
Proximal Tibiofibular Joint- tibular position. and motions of fibula
= Separate synovial joint at the knee = Oblique angulation- lateral anterior to medial posterior position* =Motions at proximal and distal fibula are reciprocal* =Dorsiflexion - foot- moves distal fibula posteriorly, proximal fibula glides anterior =Opposite with plantar flexion (fibular head posterior)
Restrictive Barrier
A functional limit within the anatomical range of motion, which abnormally diminishes the normal physiologic range' (Glossary) A = anatomical P = physiological R = resistance
Segmental definition: supine ASIS
ASIS Evaluation Position Thumbs immediately inferior to both bony prominences S/I;A/P; I/E-closer or further away from belly button ASIS Diagnosis Position Superior Inferior
difference between axial spine and rib adjustments FUNCTIONAL METHODS
AXIAL: Shoulder/Trunk input ONLY Contact transverse processes RIB: Shoulder/Trunk AND upper extremity input Contact rib angles
Motions of the foot- what does the knee and tibia do?
Abduction External rotation of the tibia Anteromedial glide at the knee Adduction Internal rotation of the tibia Posteorlateral glide at the knee
diff between active and passive motion in seg definition
Active Motion Motion accomplished by the Patient Not as consistent Used during some screening motions Passive Motion Motion generated by the Physician More consistent Used predominately during screen and scan Both should reveal the SAME osteopathic diagnosis Aside from what they are COMMONLY used for, think of why they MAY or SHOULD be used...
indications
Acute: patient unable to relax local or general muscle tension is increased Chronic: somatic dysfunction with fibrotic, shortened tissues If Tx using Ease hasn't worked Improved localization = less force needed
Adductors: NAME SOME Testing End Range & Strength Against Resistance
All cross hip joint Most arise somewhere on the pubic bone Pectineus Adductor longus Adductor brevis Adductor magnus Gracilis Descends beyond knee Actions: Femoral adduction Aid in gait Partial controllers of posture Magnus and Longus also medially rotate thigh
COMPLETE MOTOR ASYMMETRY
All motions are involved when there is somatic dysfunction present
Shoulder Complex: Scapulothoracic Joint Protraction: Muscular Involvement in protraction:
Anterior Element: Pectoralis Minor Lateral Element: Serratus Anterior
pelvic dysfunctions
Anterior innominate rotation Posterior innominate rotation Superior pubic shear Inferior pubic shear Superior innominate shear ("Upslip") Inferior innominate shear ("Downslip") Inflare Outflare
Dysfunction: Knee
Anterior tibial glide Posterior tibial glide Medial tibial glide Lateral tibial glide Anteromedial tibial glide Posterolateral tibial glide Most common: anteromedial glide, medial glide and posterior glide
Techniques/Skills
Anterior/Posterior Fibular Head -ME -Direct/Indirect Anterior Posterior Glide Dysfunction, Knee -Direct/Indirect Interosseus Membrane -Indirect Anterior/Posterior Talus -ME -Direct/Indirect Subtalar Inversion/Eversion -Indirect Plantar Navicular/Cuboid/Cuneiform -Direct/Indirect Dorsal/Plantar/Medial/Lateral Metatarsal -Direct/Indirect
What landmarks do you need to segmentally define the pelvis?
Anterior: iliac crests, ASIS, pubic tubercles, medial malleoli* Posterior: PSIS, ischial tuberosities *check motion at sacrotuberous ligament (**)
SacroIliac articulation
Apply gentle, springing ANTERIOR, SUPERIOR presure at ILA. Springy? Concrete, unyielding?
What is happening during treatment?
As the patient initially flexes the trunk, the sacrum becomes extended bilaterally This takes the sacrum to the restricted barrier As the patient tries to extend, this causes the sacrum to flex bilaterally The physician uses a counterforce at the thoracic region, which causes isometric contraction at the lumbosacral junction As the patient relaxes, the trunk is able to flex further and increased sacral extension is able to occur HAVE THEM INHALE to modify
lower half #2 2) Pubic bone dysfunction
Assess landmarks: pubic tubercles Treat asymmetric side If no asymmetry: Use AB/Adduction muscle energy 2-3 times in each direction
Gluteus Medius and Minimus: Gluteus Medius Tenderpoint
Attached to external iliac surface Attach distally to greater trochanter Actions: Abduct thigh Internal rotation Keep trunk upright when opposite foot is raised in walking and running Active in Romberg's test Point location: below iliac crest along upper portion of gluteus medius Treatment: extension, internal rotation, slight abduction
Diagnosis Review & Treatment -Metacarpals/Phalanges
Balanced ligamentous tension(BLT), aka ligamentous articular release (LAR) - Any dysfunction Stabilize proximal joint Disengage: compression or traction Exaggerate ease Balance (follow) ease Can also use the phase of respiratory ease to adjust motions Recheck Naming?
Bilateral Sacral Dysfunctions
Bilateral Flex Sacrum Bilateral Extended Sacrum Note: movement occurs around the middle transverse axis
Rotation Vs. Sidebending
Both extremely useful Some people prefer one over the other Usually combination of both Rotation: Place segment into ROTATIONAL restriction Sidebending: Place segment into SIDEBENDING restriction
Cervical Segmental Somatic Dysfunction/Deep Muscles
C4 ER(R)S(R) -Gently support cervical region with index finger on C4 -Flatten the cervical lordosis -Add compressive force to C4, directed through head and neck. -Extend neck through level of C4 -Slightly sidebend and rotate to right to maximal ease -Hold 3-5 seconds -Slowly return to neutral -Recheck
Posterior Scapular Muscle Diagnosis & Treatment:
Caudad Hand: Thumb & Web cup the inferior angle of the scapula Cephalad Hand: Contacts the lateral shoulder and the superior border of the scapula With these contacts you can engage stretch for any of the muscles listed. Is it tight? It may be obvious or you can compare with the opposite upper extremity Treatment: Lengthen the muscle to stretch it Direct stretch or Muscle energy Trapezius Levator Scauplae Rhomboid Serratus Anterior
Neutral External Rotation Treatment (Tight Internal Rotators)
Cephalad Hand: Contacts the ASIS from its lateral side Caudad Hand: Contacts the greater trochanter anteriorly The two hands push away from each other to create an external rotation stretch at the hip joint Often a factor in the geriatric population with hip pain
Anterior Innominate ME Treatment
Cephalad hand- L ASIS Caudad hand- L ischial tuberosity Flex knee and hip Adduct LE to gap SI Instruct pt to push knee into chest (gently!!) Repeat 3xs, recheck Obj: rotate innominate posteriorly using isometric counterforce
motions can be used for these regions too
Cervical Thoracic Lumbar Sacrum Rib Cage
Local Deep Pressure for Cervical! and Lumbar!
Cervical You may need to gently support the forehead when using local deep pressure scanning with a SEATED patient. Lumbar Sitting on a stool or kneeling will allow you to use this approach to scanning for the SEATED or STANDING patient
O-A Supine Nodding Test*
Chin deviated to 1 side -Occiput rotated to that side -Sidebent to opposite side Unilateral flexion -Rotation to same side -Sidebent opposite Unilateral extension -Rotation opposite -Sidebent to same side
Spring Test
Classic Test: Anterior pressure at the sacral sulci Normal: should spring/have resiliency Positive Test: Base is resistant, does not spring, feels like concrete Meaning: Base is stuck in extension or posterior (it will not go into flexion) ILA testing: Positive test: ILAs are resistant to anterior pressure, do not spring
dysfunction trick for anterior ribs BUCKET HANDLE
Compare intercostal space above and below for width: Space above 'Wide' (below, 'narrow') = exhalation dysfunction (resists inhalation) Space above 'Narrow' (below, 'wide' = inhalation dysfunction Confirm by Comparing its response to inhalation/exhalation with that of the one on the other side or with the rib above and below.
4. Thoracic/Other Ribs: Treatment
Counterstrain/Functional Methods/Muscle Energy (HVLA - will learn later Winter quarter; LAR in year 2) You already know how to treat somatic dysfunction in this region.
The Diagnostic Process - Scan
DEEP = ANTERIOR SHALLOW = POSTERIOR sacral base PSIS: Have your patient lie prone Follow the iliac crests posterior to their limit - the bottom of the PSIS. Move thumbs superiorly onto the main part of the PSIS, its posterior prominence. SACRAL SULCUS Move thumbs medially from the PSIS a thumb breadth - thumbs now over sulci. Use your "awesome" palpatory skills to determine if one sulci is deeper or more shallow than the other Follow the spines of the sacrum inferior until your index finger drops into a 'hollow', the sacral hiatus. The posterior aspect of the ILA is just 2-3 cm lateral to and on either side of the sacral hiatus.
kneading type
DEEP friction- short, deep thumb strokes -petrissage- wringing, rate, rhythm and type of pressure- like kneading dough -skin rolling- may be painful- stimulating petrisage
muscle energy thoracolumbar junciton- diagnosis- DIRECT STRETCH TECHNIQUE
Diagnosis: Patient seated: Contact the lateral inferior border of the 12th (or 11th) rib Press gently superior and laterally; compare with opposite side for ease/resistance Determine the tight side. Treatment: Same position and contact Press gently superior and lateral on the under side of the rib Carry the patient into flexion & sidebending until the 'feather edge' of resistance is encountered Continue as a direct stretch, or Have patient try to side bend back to neutral (muscle energy
Muscle Energy Technique - Rib Posterior Subluxation Treatment - Right 5th Rib
Difference with Tx for Anterior Subluxation: Posterior Thumb pressure is MEDIAL Isometric force: pt. tries to adduct elbow and physician resists
diagnosing anterior ribs
Diganosis: Listening: Index fingers contact the anterior rib cage sequentially, at the level of each rib Motion: Use forearm contact bilaterally to introduce rotation right and left alternately Feel for a sense of increased localized tension during rotation under one of the palpating fingers Localized increased tension = a rib fulcrum Start at rib one and work down assess responses to Rotation Flexion/Extension Sidebending Translations Using the forearm contact and the Osteopathic belly, carry the patient into the directions of resistance The localization of tension should be confined to the diagnosed anterior rib fulcrum. Use the Muscle Energy treatment sequence
Treatment Options
Direct Find resistance position of joint Move through that resistance by muscle energy, springing, or thrusting Indirect Find position of ease in all planes and phase of respiration Refine position as release occurs
Treatment: Knee
Direct Find resistance position of joint Use muscle energy or springing to activate Indirect Find position of ease in all planes Use breath as activating force
Diagnosis Review & Treatment -Sternoclavicular Jt
Direct Springing-Anterior & Superior Glide -Doc places caudal hand on the table and cephalad hand on inferior portion of the proximal clavicle -Patient uses opposite hand to stabilize the arm -Spring posteriorly and inferiorly-lateral -Recheck
Scan: supine ASIS compression
Direct compressive pressure at ASIS... ...directed towards the Posterior Articulation of Innominate and Sacrum (i.e. The SI joint) ...gives you information about the motion that joint is able to perform. Springy vs Concrete Compression test. Ease of motion in the A/P planes is noted with alternating, rocking pressure
mistakes with functional methods
Do not carry any motions too far because you could actually increase tension There is such a thing as positioning "past" ease This can be used to refine your sense of optimal ease as you learn. Not necessary after you become more comfortable with the feel of 'ease'
Functional Technique- Cervical Positioning
Doc seated at the head of the table Use finger pads of your middle finger to palpate segment and use your palms to input motion
Pubic shear: Right PT Superio TREATMENTr
Doctor carries R leg into extension Added ABduction, external rotation will gap the pubic bone to allow for inferior movement Doctor stabilizes at contralateral ASIS Provides resistance at ipsilateral knee Patient directed to "bring leg back on to the table"
Dysfunction: Metatarsal + motion
Dorsal/plantar glide Medial/lateral glide Treatment Direct Seated or supine. Stabilize metatarsal in question. Articulate MT through range of motion. Treatment Indirect Seated or supine. Balance metatarsal into ease, use breath to facilitate release, reposition accordingly
goal of med records during visit
During Visit: Identifies somatic dysfunction in a region by use of altered tissue texture and motion asymmetry Allows for immediate visual recall of observation
Sacral Motion: Oblique Axes naming- when is dynamic motion important
Dynamic Motion: physiologic Occurs during ambulation Weight bearing on Left leg will engage left axis and vice versa Right and Left Named for the side of the upper pole of the oblique axis!!
tricks
Dysfunction on an oblique axis: 1. Determine axis and place axis down 2. Determine forward/backward torsion (Pt on chest if forward, back if backward) 3. Position legs accordingly (Front 2 Back (1) )
Eight Essential Steps to ME- AEP MC RRR
Eight Essential Steps: Accurate Structural Diagnosis Engage restrictive barrier Provide Unyielding Counterforce Muscle Effort Appropriate for the Patient Complete Relaxation Repositioning Repeat 3-6 for Three to Five Repetitions Retest - What change has occurred?
Scalene -origin insertion function and motion
Engages pump and bucket handle of Ribs 1-2 Originate at the transverse process of C2-7 and insert on Ribs 1 and 2 Function: sidebend the neck ipsilaterally
Innominate Outflare Muscle Energy Treatment
Ex: Right Doc: Flex R hip and knee, Adduct R hip Doc's L hand monitors at R PSIS Pt moves knee out while doc resists May offer more adduction, repeat and recheck **Opposite treatment as inflare**
Innominate Inflare Muscle Energy Treatment
Ex: Right Doc: Flex R hip and knee, Abduct R hip to restrictive barrier while stabilizing L ASIS Pt moves knee toward midline while doc resists Repeat, add further abduction, recheck
rib preferring exhalation does what?
Example: Rib 4 exhalation ease (inhalation resistance) Pattern of Ease: Abduction External Rotation Cephalad Compression
Treatment of Ribs: Inhalation vs Exhalation
Exhalation ribs are "stuck down" We are going to engage muscles to pull them up Inhalation ribs are "stuck up" We are going to apply force directly on ribs to push them back down
The Diagnostic Process: 'Sphinx Test'
Extend bacl flex sacral base- Patient sulci depths are tested neutral prone first Patient assumes the prone- prop position (sphinx) Lumbars extend, sacrum flexes Negative Test: Decreased sacral base asymmetry= sacral flexion ease Positive Test: increased sacral base asymmetry = extension ease
Mechanics of External Rotation of the Hip
External rotation of the right hip Results in rotation of the spine in the opposite direction (which is left in this example)
thoracic spine prior to rib cage, TXT SEQUENCE
FM, ME, Impulse (direct) --> HVLA
FPR is different from SCS HOW!?
FPR- Looking for tissue tension/ activating force CSC- looking for tender point/no force BOTH FIND EASE, BOTH ARE INDIRECT METHODS
C2-7 Motion**** dysfunction
Facet surfaces always in contact unless traction applied No physiologic neutral Facets always engaged Only non-neutral somatic dysfunction =Always "Type II like" =No group somatic dysfunction Sidebending and rotation to same side 99% of the time no NEUTRAL SEGMENTS - Always flexed or extended and FRS (R and S in same direction)
FPR procedure! NAME ALL 6 steps
Find dysfunction Flatten the curve Compress to dysfunction Add rotation/side bending ease Hold 3-5 seconds Recheck
Anterior ribs
Find the same rib anteriorly. Contact is at the costalchondral junction. Find sidebending,rotation, and flexion or extension ease Now have the patient take a deep breath in and exhale. If the patient favors exhalation the rib moves down easily and the tissue becomes less tense under your finger
Anterior Innominate Rotation
Findings (e.g. Left Anterior Innominate) + standing flexion on left side L ASIS inferior L PSIS superior L medial malleolus may be inferior L sacrotuberous ligament loose Normal Physiologic Motion (iliosacral) Tight quads
Inferior Shear Typically caused by muscle imbalance
Findings: + standing flexion test Ipsilateral pubic bone inferior +/- Tension and tenderness of ipsilateral inguinal lig.
Vertebral distance Finger width
Finger width
Lumbar Motion
Flexion/Extension Primary motions Increases from above downward Side Bending Small amount Evenly distributed Rotation Minimal Coupled motion Neutral and Non-neutral
T7 Flexed RRSR Supine ME technique
Force is localized through the elbows to the thenar eminence. Sidebend, extend and rotate for localization using the head & neck motion input Pt. uses isometric force against the physician. Reposition for localization into resistance Repeat, Recheck
Motions of the foot- inversion and eversion
Forefoot inversion (supination strain) Talus glides posterolaterally at talocalcaneal joint relative to the navicular Forefoot eversion Talus glides anteromedially
Determinates of Motion- fryette's 3rd
Fryette's Third Principle Initiation of motion of a vertebral segment in any plane of motion will modify the movement of that segment in other planes of motion
treatment of dysfunction with muscle energy
GOAL: Put the dysfunction where it doesn't like to go!!==Barrier SEGEMENTAL DEFINTION==EASE of motions Muscle energy== away from ease so you do the opposite motions of segemental definition.
OA: Flexed side bent right rotated left
Goal: Carry the left occiput forward on the atlas Force must be directed: -Superior to disengage the facet joint -Medial & Anterior to follow the plane of the facets The Resulting Vector is Toward the Opposite Orbit Dx: FSrRl
OA: Extended side bent right rotated left
Goal: Carry the right occiput backward on the atlas (stuck facet) Force must be directed: -Superior to disengage the facet joint -Medial & Anterior to follow the plane of the facets -Toward the Opposite Orbit Notice the Subtle Change in Vector & Localization toward the right facet joint Dx: ESrRl
thrust is 2 features
HIGH VELOCITY LOW AMPLITUDE- short distance-
Elbow Complex: components
Humeroradial Joint Humeroulnar Joint Interosseous Membrane
Fryette's principles
I. neutral SB before R OPPOSITES II. non-neutral R before SB- same side III. motion in one plane affects motion in other planes THORACIC AND LUMBAR ONLY
your are looking for what kind of response*
IMMEDIATE-
LOW BACK COMPLEX
Iliacus Gluteus Medius Piriformis Sacrum (PIGS)
Somatic Dysfunction
Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements.
Practice HVLA- cervical, thoracic, lumbar
Important points- 1. motion of C2 is primarily rotation-HVLA here is rotation into resistance 2. cervicals C2-7 behave Fryette like- Type 2 mechanics- rotation and side bending opposite directions (NO WRONG SAME) 3. correct upper extremity position for thoracic HVLA 4. Flexed and extended thrust direction 5. Practice ! Contact your friendly local OMM fellow for assistance
Bilateral Sacral Extension Bilateral Sacral Flexion
Improper lifting techniques Fall in seated position Patient can't backward bend or it is very painful. Extremely common postpartum Arched with a heavy load Patient can't forward bend or it is very painful.
Unilateral Extended Sacral Dysfunction WHAT IS GOING ON?
In a left unilateral extended sacrum, the left sulcus is posterior and the left ILA is anterior Pressure is held on the ischial tuberosity to keep the innominate from rotating and moving inferior during the activating force Springing at the left sacral base forces the left sacral sulcus into flexion (the motion that is restricted) Springing is continued until restricted barrier is passed (softening of resistance occurs & motion is more like the other 'normal' side.
L5 in torsions? RULES TO DIAGNOSING L5
In a torsion, L5 Sidebends into the axis, Rotates opposite sacrum Rule #1: When L5 is sidebent, a sacral oblique axis is engaged on the same side as the sidebending. Rule #2: When L5 is rotated, the sacrum rotates the opposite way on an oblique axis. Rule #3: The seated flexion test is found on the opposite side of the oblique axis L5 will always rotate in the opposite direction of the sacrum L5 will always be sidebent towards the side of the sacral oblique axis (when normal mechanics are operating; trauma can change that)
Rib 1b: The Lazy Student's Question
In supine position, upper extremity is flexed above the head, elbow slightly bent. Forearm is placed on operator's palpating arm, fine tuning with traction and further flexion of the arm until tender point is relieved.
Posterior Rib 7-10
In the seated position, add extension with rotation and sidebending to the same side as the tender point.
Inferior Shear
Inferior Shear Typically caused by muscle imbalance Findings: + standing flexion test Ipsilateral pubic bone inferior +/- Tension and tenderness of ipsilateral inguinal lig.
Inferior Shear (Down Slip) Foot entrapment HOW DOES THIS HAPPEN?
Inferior Shear (Down Slip) Foot entrapment Landmark findings Iliac crest: ↓L ASIS: ↓L Malleolus: ↓L PSIS: ↓L Ischial Tuberosity:↓L Pubic bone: ↓L
Sacral Movements and Respiration:
Inhalation causes sacral extension (base goes backward) Exhalation causes sacral flexion (base goes forward) Therefore... We can use the phases of respiration to treat unilateral sacral lesions!
DIAGNOSIS for muscle energy of ribs
Inhalation rib or Exhalation rib" with 'Bucket handle &/or Pump handle' elements i.e. Right rib 4 inhalation dysfunction, pump handle primary
Two Questions you must answer to decide upon the ME treatment: for RIBS
Inhalation/Exhalation Dysfunction? Primarily Bucket handle &/or Pump handle motion? [ribs 11 & 12: caliper motion] -NOT Flexion/Extension, Sidebending, Rotation
Fryette's 3rd Priniciple:
Initiating motion at any vertebral segment in any one plane of motion will modify the mobility of that segment in the other two planes of motion -Positioning with sidebending will decrease the amount or repositioning needed with rotation and flexion/extention.
OA Alternative Tests
Intersegmental Motion testing Hands supporting occiput with index fingers in occipital sulcus lateral to midline. Motion is induced while fingers are monitoring response. One hand supporting occiput with index finger and thumb of other hand stabilizing and monitoring motion at occipital sulcus lateral to midline. Monitor response while motion testing *Side of shallow sulcus is the side of sidebending preference *Flexed or Extended position: Whichever the sulci are most even is the direction of ease
OA ME
Introduce side bending to restriction by translating the segment to restriction Rotate to restriction Instruct patient to move head into one position of ease ( F/E, R, or SB) against counterforce Hold 3-5 sec. Relax, Reset, Repeat, Recheck
Dysfunction: Subtalus + motion
Inversion/eversion of calcaneous With associated posterolateral/anteromedial talus Treatment Indirect Seated or supine Stabilize talus, find balanced ease in calcaneous, use breath and reposition as spontaneous release
Segmental definition:Prone Ishceal tuberosities
Ischial tuberosities: Position: Cephalad Caudad
Motions: KNEE and a bunch of other
KNEE =Lateral/Medial =Anterior/Posterior =Anteromedial (EXT rot)/Posterolateral (INT rot) Fibular head motion Lateral Malleolar Motion Strain to Interosseous Membrane Ankle Motion -Talotibial motion -Subtalar motion -Intertarsal motion
To induce flexion
Keep lower knee slightly flexed Draw upper extremity slightly inferior
alternative ME technique
L4 ESlRr lateral recumbent on left side with legs bent to induce flexion, pulled up to induce Sr, and R the knees left to push more into restriction. SO.... "Pulling your feet to the floor" would normalize the action towards ease.
Longitudinal Arches
Lateral Calcaneus, cuboid, and metatarsals 4 and 5 Medial Talus, navicular, three cuneiforms, metatarsals 1-3
OA: Extended side bent right rotated left
Left Hand contacts left occiput at the AO articulation Right Hand cradles the head and neck. Goal: Carry the right occiput backward on the atlas - toward the opposite orbit -Sidebend Left Rotate Right into resistance Patient Relaxation: ='Take a deep breath in, then let it out slowly.' ='Let your head drop toward the table.' Dx: ESrRl
Q Angle
Less than 15 degrees in men Less than 20 degrees in women -Increase in Q angle can result from excessive ankle pronation -Increase in Q angle may result in patellofemoral syndrome
Iliacus Tender point
Location: medial and inferior to the ASIS several cm Treatment: Cross ankle of involved LE over the other ankle Flex, externally rotate Frogleg Position Rest ankles on physician's thigh - foot must be up on the table
Tensor fascia lata Tenderpoint
Location: 12 cm below greater trochanter along lateral surface Treatment: ABDUCTION
Piriformis Tenderpoint
Location: middle of the gluteal region; in the body of the piriformis muscle Treatment: approx. 135 degrees of flexion with abduction
complete relaxation of patient- what type of contraction do we have? explain muscle energy?
MOST IMPORTANT PART. Will not work if the patient doesn't relax completely after their muscle activation. The muscle will still be activated and so cannot be "reset". "... immediately after an isometric contraction, the neuromuscular apparatus is in a refractory state during which passive stretching may be performed without encountering strong myotactic reflex opposition. All the operator needs to do is resist the contraction and then take up the slack in the muscles during the relaxed refractory period."
Remember! with motion! radial head - supination and pronation
MOTION Monitor at proximal radial head (as in previous slide) With other hand, grasp patient's hand in the handshake position Monitor proximal radial head while supinating and pronating the hand Radial Head Posterior with Pronation Radial Head Anterior with Supination
Segmental definition: supine MM
Medial malleoli Position Compare relative position of the malleoli Sup/inf?
Pump Handle Relationships of Interest, in particular
Monitor Pump handle Motion at the costochondral junction will be our primary focus initially Scan the ribs, esp. 1-6 Segmentally define the pump handle aspect Wider gap above or below? Response to respirations: Inhalation Exhalation
FPR rib
Monitor dysfunction with one hand, Reaches across cervicothoracic junction (CTJ). Forearm is over shoulder. Tell patient to sit up straight. 'Push the chest forward.' Compress downward and introduce side bending/rotation as needed. Hold for 3-5 secs, release, re-evaluate. CAN ALSO DO FACEDOWN
Pubic Shear Right PT Superior
More common of the two Typically caused by standing with weight unevenly distributed or by muscle imbalance Findings: + standing flexion test Ipsilateral pubic bone superior +/- Tension and tenderness of ipsilateral inguinal lig. Position of restriction: Bring right side inferior Anterior rotation, pubic bone dips inferiorly Patient actively seeks "ease" Superior motion.
Standing flexion: how to do it
Motion: standing flexion Monitor: PSIS Where? Active patient motion: "reach for your toes" Restriction on one side leads to premature locking at the SI joint. This PSIS elevates SOONER, moves FIRST. Positive test: dysfunction is named for side that moves. Equal motion?- negative test No dysfunction Symmetrical dysfunction
Review & Treatment -Radial Head POST and ANTERIOR
Muscle Energy - Anterior Radial Head Pronate the forearm to place radial head into restriction while palpating the radial head Have your patient supinate the forearm against your force Post isometric contraction reposition and repeat 3-5 times Recheck Muscle Energy - Posterior Radial Head Supinate the forearm to place radial head into restriction while palpating the radial head Have your patient pronate the forearm against your force Post isometric contraction reposition and repeat 3-5 times Recheck
treatment of AC joint- adduction ease treatment- ME!
Muscle energy - Adduction ease Palpate AC joint Place the pt's AC joint into restriction, abduction Have patient contract against your forearm 3-5s Post isometric relaxation Reposition joint into further restriction, repeat 3-5 times Recheck
treatment of AC joint- internal rotation ease treatment- ME!
Muscle energy - Internally rotated AC -Place the pt's AC joint into restriction, external rotation -Have patient contract against your forearm 3-5s Post isometric relaxation -Reposition joint into further restriction, repeat 3-5 times Recheck
Foot motion
Navicular bone dysfunction Plantar glide and medial rotation (inversion) Cuboid bone dysfunction Plantar glide and lateral rotation (eversion) Cuneiform dysfunction Plantar glide without rotation -Tarsal metatarsal joint motion =Generally less motion at the 2nd metatarsal =Minor motions are anterior/posterior glide, medial/lateral glide, internal/external rotation glide
THEORY BEGIND MUSCLE ENERGY
Nociceptive stimuli results in excitatory input to the gamma motor neurons. When gamma motor neurons are activated the spindle fibers are more sensitive to stretch, and thus more likely/prone to feed forward excitatory input to the alpha-motor neuron pool. Which will then likely result in even more nociceptive stimuli further exacerbating the problem. breath counts as activating force
OA Motion Testing
Nodding test -Pt. moves head into F/E -Observe for lateral deviation of chin Patient supine (Active Motion Test) -Doc standing at head of table -Patient nods head without lifting it off table -Flex- tuck chin- condyles slide back -Ext- backward nod-chin anterior- condyles slide forward -Observe for lateral deviation of chin in flexion or extension Lateral translation -Doc at head of table, hands on patient's head, elbows level with patient's head -Translate head by shifting body side to side ==Remember sidebending and translation are opposite -Test in neutral and with small degrees of F/E
Shoulder Complex
Normal motion at shoulder involves motion at multiple joints Sternoclavicular Acromioclavicular Scapulothoracic Glenohumeral All 4 joints are assessed during upper extremity Scan
lateral ribs
Now follow the same rib laterally Stop in the mid-axillary area. Sidebend, rotate and flex/extend finding the area to ease. Now have the patient take a deep breath in and exhale do the move lateral and superior with inhalation?
With one segmental dysfunction finding you need to verify with
ONE MOTION TEST--> Passive motion imput
observation
Observation Gait Posture
screening process
Observation Structural impression of postural alignment Tissue Texture Assess superficial muscle tone in 8 regions (Resistance to Pressure) Motion Assess gross region motion testing in 8 regions (Resistance to Motion)
6. Cranial-Cervical Junction/Cranium
Occiput/Atlas/Axis/Suboccipital tissues Final common pathway for all forces originating inferiorly Jugular foramen Vagus nerve Greater occipital nerve Emerges between C1 & C2
re-check?
Once back in neutral position, recheck tender point, should be 30% or less of original, ideal is 0% If not better, may not have been optimally positioned May be another primary tender point Recheck original structural findings You are treating dysfunction, not tender point
5. Scapulo-Thoracic Articulation
One of the important articulations of the shoulder Restriction is usually due to costal cage dysfunction combined with muscular imbalance Has attachments to thoracic and cervical spine, as well as rib cage Therefore significant contributor to dysfunction in those regions, as well. May secondarily change biomechanics of the glenohumeral joint Counterstrain: Ribs Pectoralis minor Trapezius Levator Scapulae Serratus Anterior Rhomboid Muscle Energy (&/or direct stretch): Ribs & same muscles
alpha-gamma coactivation theory
One performs a voluntary activation of skeletal muscle, that in addition to the activation of the alpha motor neurons, that gamma motorneurons are also activated (the theory of alpha-gamma coactivation). Thus, following the isometric contraction (and subsequent activation of gamma motorneurons) there may be a period of reduced sensitivity to the spindle fibers detecting a change in muscle length.
Pectoralis Minor Assessment & Treatment
Operator contacts the insertion of the pectoralis minor at the 3rd-5th ribs anteriorly The ipsilateral elbow is abducted sufficiently to bring the vector forces to a localization at ribs 3-5 anteriorly Abdominal contact with the patient's back brings stability during the treatment Have the patient pull the elbow forward with only sufficient force to engage the pectoralis minor at its insertion. Isometric force, Relax, Repeat, Retest
Rib 1a: The Pose of Despair
Operator puts leg on table ipsilateral to tender point, patient drapes ispsilateral arm over leg and sidebends head to that side with flexion. Operator uses head to fine tune tender point. Patient's legs may be brought up on table and flexed to opposite side for further effect.
pec minor origin insertion and function
Originate at ribs 3, 4, and 5 and insert on medial coracoid process. Engages pump handle motion
Serratus Anterior origin insertion and function and motion
Originates on the lateral aspects of as many as ribs 1-9 (varies per source) and attaches to the scapula from the superior angle, down along the medial border, and to the inferior angle. Function: Protracts the scapula, and assists with upward rotation Engages bucket handle motion
goal of med records
Overall Goals of Record: Initial Record of Somatic Dysfunction Evaluation of Response to OMT (short-term/long-term) Longitudinal Record of Musculoskeletal Health
how to test position and motion
POSITION 1. Thumb anterior to proximal radial head 2. Index and middle finger on posterior aspect of proximal radial head 3. Compare Bilaterally MOTION Monitor at proximal radial head (as in previous slide) With other hand, grasp patient's hand in the handshake position Monitor proximal radial head while supinating and pronating the hand Example: Objective Findings: Proximal Radial Head Anterior Assessment: Somatic Dysfunction of the Upper Extremity
Humeroulnar Joint Position and motion
POSITION Grasp Elbow with both hands Evaluate for increased/decreased carrying angle and compare bilaterally MOTION Using both hands, grasp the proximal ulna Place patient's wrist between physician's elbow and trunk Add translatory force medially and laterally (adduction/abduction) Compare Bilaterally Example: Objective Findings: Right Elbow increased carrying angle with right humeroulnar joint abducted Assessment: Somatic Dysfunction of Upper Extremity
Segmental definition: Prone
PSIS Position: compare heights Superior? Inferior?
Posterior Innominate Rotation
PSIS down ASIS up Medial Malleolus Up ALLL on one side
palpation landmarks for sacrum
Palpation Nomenclature Anterior and Deep When the sacral base moves anterior the sulcus/sulci can be said to be anterior or deep. Posterior and Shallow When the sacral base moves posterior the sulcus/sulci can be said to be posterior or shallow.
Left on Left Torsion TXT sequence
Patient Prone Doctor on opposite side of axis With the patient's hips and knees flexed to 90°, roll the patient onto their hip such that the axis is DOWN Physician Monitors at Lumbosacral junction Physician supports patients knees (with thigh) and lets ankles drop to floor Continue to monitor lumbosacral jn ME Treatment: patient pushes ankles to ceiling while physician restricts motion Patient relaxes, take up the slack, then the ankles are allowed to drop further to floor Perform 3-5 times Localize: may need to readjust flexion/extension after muscle contraction in order to bring the forces back to the right sacral sulcus (sacral base)
Treatment - Left Unilateral Flexed Sacrum- DONT FORGET TO USE BREATH
Patient Prone Physician on side of dysfunction Knee is flexed to 90 degrees, and the leg is abducted and internally rotated. This causes gapping at the SI joint Physician monitors at SI Joint Leg is stabilized by physicians chest Caudad hand on the ipsilateral ILA, cephalad hand monitors SI joint Avoid the coccyx with right hand! Physician engages restrictive barrier by placing anterior, superior pressure at the ILA With the barrier engaged, patient assists by inhaling deeply to move sacral base posteriorly and holds the breath in while physician continues with pressure at ILA. After cycle, physician engages new barrier at ILA and another deep breath is held Repeat 3-5 x's
Anterior cervical fascia release—seated [new technique] CHOKE
Patient Seated Place thumb pads between the two heads of the sternocleidomastoid muscle on each side Patient slumps - back and neck Let the thumbs follow the tissue inferior (not much posterior) Hold that position with the thumbs as the patient inhales, holds breath and straightens up
patient and physician bodily position for ME
Patient Seated: Feet on the floor Physician Standing: Behind patient To side of side bending resistance (to provide physical support for the patient as they are sidebent into resistance)
Exhalation Dysfunction Rib 1-10 - Pump Handle:
Patient Supine, Doctor contacts inferior aspect of rib; finger pads contact via interspace below the rib (chondral) Monitors and supports inhalation phase. Extend spine, if possible Respiration is activating force, patient takes a deep breath, doctor follows the rib with inhalation & resists exhalation. Reposition (increase extension?) REPEAT (3-5 times) RECHECK Engaging resistance is augmented by extension of the axial spine - use the Head of the table
Inhalation Dysfunction Rib 1-10 - Bucket Handle
Patient Supine, Flex the spine to dysfunctional segment, supported for doctor Add sibebending toward the rib Doctor contacts superior aspect of rib monitor anteriorly Respiration is activating force, patient takes a deep breath, doctor resists inhalation and follows the rib more with exhalation Reposition (increase flexion and sidebending) REPEAT (3-5 times) RECHECK Engaging resistance is augmented by flexion & sidebending of the axial spine
treatment
Patient Supine-arms crossed 2. Doctor - Stand on the opp side - posterior TP 3. Holding pt's head, place thenar eminence under the TP of the dysfunctional segment 4. Flex pt's head until feeling motion at that segment 5. Position pt's elbows for your comfort 6. Pt takes breath in and out 7. Thrust will be in exhalation through pt's elbows into your thenar eminence
Functional Technique- Thoracic/Lumbar Positioning
Patient is seated with arms crossed At the end of the treatment table Doc on the side of sidebending ease Example - SB ease to left Doc stands on left side of patient The left upper extremity reaches under the opposite armpit of the patient
...
Patient prone Physician on side of dysfunction Physician places caudad hand on the inferior portion of left ischial tuberosity and cephalad hand on left sacral sulcus Ischial tuberosity is carried superiorly toward sacral base Left sacral base is carried anterior and inferior to the restrictive barrier Physician uses Low Velocity, Moderate Amplitude (LVMA) springing with both hands into the restrictive barrier
Supplemental Exercises for Rhomboids
Patient prone, doc on side being tested Ask patient to activate rhomboids, by pulling scapula inferiorly and medially towards the spine Monitor along superior medial border of scap Retraining: Jet fighter plane arms!
Downslip, Left
Patient prone; hip and knee flexed, draped over side of table, with foot contacting thigh of doctor Doctor adds cephalad pressure through ischial tuberosity; pressure through knee contact to "loose pack" the SI joint. Patient attempts to straighten leg against doctor thigh.
Treatment - Bilaterally Extended Sacrum
Patient seated Physician places caudad hand at sacral bases, and cephalad hand around patient's chest Patient is asked to extend trunk until restricted barrier felt at sacral base Patient is instructed to flex trunk as physician restricts movement with cephalad hand. During flexion, physician also uses caudad hand to restrict sacral extension Patient holds contraction for 5 sec As patient relaxes, the trunk is furthered extended until a new barrier is felt at the sacral base Repeated 3-5 x's.
Treatment - Bilaterally Flexed Sacrum- LEVER
Patient seated Physician places caudad hand on sacral apex and cephalad hand on thoracic region Patient flexes trunk until resistance is felt at the sacrum by the physician Patient actively extends trunk, while physician resists motion with cephalad hand Patient holds extension for 3-5 sec then relaxes. As patient relaxes, pressure is continued on the sacral apex, and the patient flexes until a new barrier is reached Repeat 3-5 x's
FPR-Lateral Rib
Patient seated Physician standing behind patient Physician axilla at the CT junction Monitor dysfunctional rib Grasp flexed elbow and abducted arm 45 degree Ask patient to straighten up Compress to the dysfunction Hold 3-5 seconds Recheck
T4-T12 Springing
Patient seated- doc standing in front Patient crosses forearms Doc passes arms under patient forearms and over shoulders to monitor segment with fingertips Patient drawn forward, flexing at hips Thorax extended to restriction Apply spring until release Recheck
Stretches to Teach: Levator Scapulae
Patient seated: Patient holds on to the side of the chair with one hand and flexes the head as if looking and into the opposite breast pocket. Free hand is placed on the head and a gentle stretch is placed inferior and slightly lateral. Hold for 5-15 seconds and repeat.
1st Rib
Patient supine Physician on the side of the dysfunction Contact the first rib with the hand closest the patient With the other hand abduct the patient arm with the elbow flexed Compress into the dysfunction Internally rotate and adduct the arm Release and recheck
Upslip, Right
Patient supine, doc at end of table. Doc grasps RLE, just above ankle, braces L foot against thigh inducing ABduction and INternal rotation to gap SI joint Added traction encourages R innominate into restriction Instruct patient to bring R hip superiorly towards R shoulder, or like they are "pulling foot out of a tall boot"
Thoracic HVLA: Extension Only T4-T12
Patient supine-doc stands at either side Pt. arms crossed-opposite on top Use caudad hand to support B/L TPs, Lift head into flexion Localize to your TP contact Thrust posterosuperior through patient's elbows Creates a Flexion force at the dysfunctional segment Recheck
C2-7 Muscle Energy
Patient supine/Doc at head of table Support occiput in palm Index finger over articular pillar of segment, on side of SB resistance Flex or extend to restriction at segment using opposite hand Introduce side bending to restriction by translating the segment to restriction Rotate to restriction Instruct patient to move head into one position of ease (sidebending) against counterforce Hold 3-5 sec. Relax, Reset, Repeat, Recheck
Non-neutral Extended RSleft Supine ME Prep Technique SUPINE
Patient tries to pull backward toward the table
why patient arm above head in exhalation dysfunction 11-12 rib
Patient's arm position uses the latissimus dorsi to facilitate the movement of the rib up (into restriction) while resisting the action of the quadratus lumborum
treatment?
Patient: Lateral Recumbent Physician: Standing in front of and facing the patient
Standing flexion test
Performed when scanning the pelvis For pelvic dysfunction Indicates __ILIO-SACRAL__________ component of dysfunction
Seated flexion test
Performed when scanning the sacrum For sacral dysfunction Indicates _SACR-OILIAC__________ component of dysfunction
what can contribute to sacral dysfunction of the innominate?
Piriformis can contribute biomechanically to sacral dysfunction
Piriformis origin and insertion
Piriformis: Arises from the anterior surface of the sacrum; If hypertonic or contractured, can create a relatively fixed pivot around which the sacrum must move.
Shoulder Complex: Scapulothoracic Joint Position Supine
Place palm of hand on each anterior aspect of each shoulder Gently compress both shoulders and assess for resistance Side of resistance = side of shoulder protraction
Lumbar Soft Tissue Treatment—Hypertonic Left Low Back Muscles
Place pt's right ankle over left Reach around and grasp pt's right thigh from the lateral surface. Extend posteriorly Externally rotate contralateral leg/ hip (causes the spine to rotate left) The torque is the Activating Force Hold for 3-5 seconds and release slowly toward neutral Recheck
Standing Flexion Test (Scan of Pelvis)
Place thumbs under PSIS Ask pt. to slowly bend at waist Watch for thumb movement (superior/anterior) Side that moves first is the positive side
Dysfunction: Navicular/Cuboid/Cuneiform +motion
Plantar and medial rotation—navicular Plantar and lateral rotation—cuboid Plantar cuneiform Treatment Direct ("Hiss Whip") Patient prone, thumb over plantar dysfunction, plantar flex to resistance, move foot "to and fro," then rapid short thrust through resistance Treatment Indirect Balance ease in all planes, use breath, re-establish position in release
Shoulder Complex: Glenohumeral Joint Position
Position -Patient seated with physician behind -Thumb on acromion -Middle finger on anterior aspect of humeral head -Compare distance between thumb and middle finger bilaterally Motion Thumb on acromion Index and middle finger on anterior aspect of humeral head Squeeze thumb and fingers together Compare resistance to glide bilaterally Ex: Objective Findings: Right Anterior humeral head preferring anterior glide Assessment: Somatic Dysfunction of Upper Extremity
Scapulothoracic Joint- position and motion
Position Protracted vs Retracted Superior vs Inferior Rotated Upward vs Rotated Downward Motion: SAME Palpate landmarks and compare bilaterally
Acromioclavicular Joint position and motion
Position: "Stair-step" - drop off from clavicle Motion: Abduction vs Adduction Internal Rotation vs External Rotation Follow clavicle distally to acromion Place index finger on distal clavicle Place middle finger on acromion Palpate for "stair-step" Compare bilaterally
Elbow Complex: Humeroulnar Joint- position and motion- carrying angle
Position: Abduction vs Adduction Motion: Major Motion: Flexion vs Extension Minor Motion: Abduction vs Adduction
Glenohumeral Joint Position: and Motion
Position: Anterior vs Posterior Motion: Voluntary: Flexion vs Extension Abduction vs Adduction Internal vs External Rotation Involuntary Motion: Slide/Glide with voluntary motion directions
Wrist: Carpal Bones and Metacarpals: Position and Motion
Position: Superior vs Inferior Internally vs Externally Rotated Motion: Evaluate for superior vs inferior glide Evaluate for internal vs external rotation Evaluate each carpal bone and metacarpal and compare bilaterally Example: Objective: Right Lunate Ventral Assessment: Somatic Dysfunction of the Upper Extremity
Sternoclavicular Joint - position and motion
Position: Superior/Inferior Anterior/Posterior Superior/Inferior Glide Anterior/Posterior Glide Rotation This is the only bony attachment of your arm to the body! Eek Important for proper shoulder motion Only bony articulation to attach UE!
Humeroradial Joint Position: and motion
Position: Radial Head Anterior/Posterior Motion Radial Head Rotation on Humerus Anterior with Supination Posterior with Pronation
Treatment of 1st Rib: Bucket Handle Exhalation ME
Position: Pt places hand on forehead: looking 40° toward the lesion Counterforce: Doctor disengages rib head with anterior/lateral pressure, hold head down Contraction: Patient asked to raise head off the table
Treatment of 1st Rib: Pump Handle Exhalation ME
Position: Pt places hand on forehead: looking straight ahead Counterforce: Doctor disengages rib head with anterior/lateral pressure, holds head down Contraction: Patient asked to raise head off the table
Treatment of Ribs 2-10 : Pump Handle Exhalation ME
Position: Pt places hand on forehead: looking straight ahead Counterforce: Doctor disengages rib head with anterior/lateral pressure, resists horizontal adduction Contraction: Patient asked to pull elbow down and across chest
Treatment of Ribs 2-10 : Bucket Handle Exhalation ME
Position: Pt places hand on forehead: looking straight ahead Counterforce: Doctor disengages rib head with anterior/lateral pressure, resists lateral adduction Contraction: Patient asked to pull elbow down and along table
Treatment of Ribs 2-10:Pump Handle Inhalation
Position: Pt places hand on forehead: looking straight ahead Counterforce: Doctor holds anterior ribs inferior as muscles contract Contraction: Patient asked to pull elbow into hand and across chest
Treatment of Ribs 2-10 : Bucket Handle Inhalation
Position: Pt places hand on forehead: looking straight ahead Counterforce: Doctor holds lateral ribs in place as muscles contract Contraction: Patient asked to pull elbow down and along table
Scan: Ankle
Position: Talar dome Motion: Talar glide
Scan: Knee
Position: Tibial tuberosity Motion: Tibial rotation
Seg.Def. Prone PSIS. what ligament do you look at ?
Position: compare heights -S/I Ischial tuberosities Position: compare cephalad, caudad Sacral Tuberous Ligament Tight? Lax ? Sacral sulci Position: compare depth- A/P
Standing flexion: what it means
Positive test: dysfunction is named for side that moves. R moves first? "positive standing flexion on RIGHT" ALL FURTHER DIAGNOSIS STEMS FROM SIDE OF DYSFUNCTION Equal motion?- negative test No dysfunction Symmetrical dysfunction
Alternative: Respiration as Activating Force - Pump Handle Treatment- exhalation and inhalation
Posterior Hand: disengages the posterior articulation (as done for Exhal. Dys. Previously) Anterior Hand: Thumb pad contacts anterior rib Exhalation Dysfunction: below the costochondral jct. (narrow part) Inhalation Dysfunction: above costochondral jct. (narrow part)
Alternative: Respiration as Activating Force - Bucket Handle Treatment
Posterior Hand: disengages the posterior articulation (as done for Exhal. Dys. Previously) Lateral Hand: Thumb pad contacts anterior rib Exhalation Dysfunction: below the costochondral jct. Inhalation Dysfunction: above costochondral jct.
Posterior Rotation: ME Treatment
Pt is supine Cephalad hand on opp ASIS, caudad hand just above knee Pt is instructed to resist into caudad hand (or bring leg up); pt is bringing innominate anterior Repeat, recheck Reminder: sacrotuberous ligament is tight on the side of posterior rotation!
Lumbar Soft Tissue Treatment—Hypertonic Left Low Back Muscles
Pt prone Pillow under abdomen to flatten the curve Doc at left side of table monitoring hypertonic area (left paraspinal region) Doc places left knee on table next to pt's ilium - this is your fulcrum Induces sidebending using knee as a fulcrum
Soft Tissue
Pt prone lateral distraction on contralateral erector spinae Pull up on ASIS as you push anterior and lateral on contralateral erector spinae
Treating the Lumbar Spine Using a Long Lever L3 E!!R(L)S(L)
Pt prone with pillow under abdomen Second pillow between pt's thigh and table Doc standing on left side Monitor left transverse process of L3 with left index finger Grasp lower ankle Abduct leg (creating left lumbar sidebending) Internally rotate leg until you feel it at your monitoring finger (this causes lumbar rotation toward left) Press left leg down towards floor (results in extension of low back) Hold for 3-5 seconds and slowly return to neutral Recheck
Pubic inferior shear: L inferior
Pt supine Doc flexes knee and hip of dysfunctional side. ABduction gaps the pubic symphasis Dr stabilizes IPSIlateral ASIS and ischial tuberosity to encourage posterior rotation, superior pubic bone motion. Patient tries to move leg toward end of table with doctor resisting. Patient directed forces should localize at pubic bone.
Right Suboccipital Muscle Hypertonicity
Pt supine Right hand: -Doc supports head -Hand on general tissue to be treated Left Hand: -Gently flatten A-P curve (slight flexion) -Add activating force of gentle axial compression Maintain compression and move head in positions of ease Hold for 3-5 seconds Release compression while returning to neutral Recheck
Rib Anterior Subluxation Treatment - Right 5th Rib
Pt's. right hand holds left shoulder Control motion of the thorax via the left hand contact with the pt's right elbow & abdominal contact with the pt's back Right thumb creates the fulcrum Via contact with the shaft of the rib, Medial to the rib angle Pt is instructed to pull the right elbow laterally or caudally Isometric, relax, repeat, retest Additional Fulcrum: Pt's left fist on anterior rib to create A-P force during contraction Fulcrum: Thumb creates & maintains posterolateral 'pull' on rib shaft
Neutral Internal Rotation Testing & Treatment (Tight External Rotators)
Pt. Prone - feet off end of table Medial Hand: Palmar surface contacts sacrum Lateral Hand: Palmar surface on the lateral gluteal musculature posterior to the greater trochanter Press anterior with lateral hand, carrying greater trochanter toward table Medial hand stabilizes with counterbalancing pressure ME or direct stretch work well End-range is often decreased and lacking resilience when dysfunctional Other approaches use a bent knee for leverage. OK if there is not knee problem.
'Iliacus Test' & Treatment
Pt. Supine - hip at edge of table Cephalad Hand: -Contact ASIS Force directed Posterior & Superior -Caudad Hand: Palmar contact just above the knee Let gravity carry lower extremity to its end-point; assess Add gentle pressure toward the floor to assess end-range resiliency Normal Range: Lift the pt's lower extremity back on to table after test Tight Muscle/Restricted Range: Direct Stretch with or without Muscle Energy
Hip Flexion/ Oblique Adduction- piriformis
Pt. Supine: Flex the hip just past 90 degrees. Then adduct, not toward the opposite ASIS, but toward the opposite chondral mass. Compare sides. The symptomatic side is usually tighter Direct stretch or Muscle Energy
alternative methods EXTENSION
Pt. supine, doc stand on opposite side of posteriorly rotated TP Pt. cross arms Rotate pt. into flexion with cephalad hand Place fulcrum (thenar eminence) under posterior TP Flex at and above dysfunctional unit Sidebend toward you to dysfunctional level Thrust posterosuperiorly into fulcrum at the stuck facet
Neutral HVLA SLRR
Pt. supine, doc stand on side opposite rotation (left) Pt. cross arms Rotate pt. into *slight flexion* with cephalad hand Fulcrum at posterior TP of dysfunctional segment Spine neutral at level of dysfunction [this is where the resistance will feel most localized] Sidebend away [(right)-opposite dysfunction] Thrust into fulcrum
Segmental definition: supine pubic tubercles
Pubic tubercles Diagnosis Position Superior, or Inferior?
Screen checks for what
REGION (2 resistance to pressure, 2 motion)
SUBOCCIPITAL REGION
RELEASE OF RESTRICTION(S) BETWEEN OCCIPUT AND SUPERIOR SURFACE OF C1 DIAGNOSIS: Place finger pads against the tissues overlying the OA/AA. Determine resistance vs. compliance (ease) TREATMENT: RELEASE TENSION OF SUBOCCIPITAL MUSCULATURE REDUCE RESPIRATORY EFFORT MAY BE ACCOMPLISHED BY VARIOUS APPLICATIONS OF FORCE
rib that prefers inhalation does what?
RIB INHALATION DYSFUNCTION - all the vowels I E A Example: Rib 4 inhalation ease (exhalation resistance) Pattern of Ease: Adduction Internal Rotation Cuadad Traction
Inflare/Outflare
Rare* Diagnosed after the correction of any other pelvic dysfunction Inflare Findings Ex. Right Standing Flexion Test positive on the right Medial ASIS on right Outflare Findings (at left) Ex. Right Standing Flexion Test positive on the right Lateral ASIS on right Anterior rotation can be associated with inflare. Posterior rotation can be associated with outflare.
rib caveat in screen and scan- motions of pump and bucket
Remember that the pump/bucket handle motion of the ribs causes the ribs to come up (suprior) anteriorly and laterally. The rib heads are anchored at the costovertebral joint. Therefore, the motions are opposite. With inhalation, ribs will move superiorly along sternum and inferiorlyat the rib angle! With exhalation, ribs will move inferiorly along the sternum and superiorly at the rib angle.
reposition
Repositioning (re-engaging resistance) Place patient into resistance at new localized restrictive barrier (F/E, Sb, R)
simplified motions
Rib 1: 50/50 Rib 2-6: Pump Handle Ribs 7-10: Bucket Handle Ribs 11-12: Caliper Motion
L5 N SLRR treatment- what muscles do you engage Left on Left Torsion
Rotating the axial spine to the left (restriction) puts the sacrum into right rotation (restriction: L rotation on L axis) Dropping the legs off the table gaps the SI joint Patient is positioned with + flexion test side up With ME, the patient is activating the piriformis and engaging the ligaments in the sacropelvic region
way to remember motions
S R F P R S respiration
how fast do you put the motions in *
SLOWLY
dynsfunction patterns. which one has L5? which one is due to sacral shear?
Sacral Torsion Rotation around an oblique axis with somatic dysfunction at L5 Unilateral Flexion/Extension Flex/Ext around a transverse axis at only one SI joint Due to sacral shearing Bilateral Flexion/Extension Flex/Ext around a middle transverse axis at both SI joints
Sacral Motion: Nomenclature
Sacral extension Base moves posteriorly In inhalation phase, sacral base moves posteriorly (AKA extends or counternutates) Sacral flexion Base moves anteriorly Occurs during exhalation, sacral base moves anteriorly (AKA flexes or nutates)
Test motions for: Scapulothrocic Joint Motions
Same contact as for testing serratus Test motions for: Protraction vs retraction Superior glide vs inferior glide Upward rotation vs downward rotation EX: Objective Findings: Hypertonic rhomboids with upwardly rotated scapula Assessment: Somatic Dysfunction of the Upper Extremity
Rib Anterior or Posterior Subluxation Treatment - Right 5th Rib -SUPINE
Same principles and contacts: Here, pt's. body weight helps hold finger pad contact against the medial aspect of the rib angle. [ or lateral for posterior subluxation]
SECONDARY muscles of respiration
Scalenes Pectoralis Minor Serratus Anterior External Intercostal Muscles Their attachments influence the pump vs bucket handle motions of the rib cage. Rib dysfunction can be treated by utilizing these muscles because of their direct attachment to the ribs. Because the ribs are all connected through intercostal muscles, influencing one rib will also influence the neighboring ribs through these connections.
Rules for screening, how many tests per region how many of each to = somatic dysfunction Rules for Scanning, how many tests per region and how many for dysfunction
Screen 2 Tissue Textures and 2 Motions for each of 8 regions At least 1 tissue and 1 motion asymmetry = Somatic Dysfunction in that region Scan 1 Tissue Texture and 2 Motions for each of 8 regions At least 1 Tissue and 1 Motion to identify a segment (2 motions if there is a tie)
screen scan and seg. def. for sacrum ALL VARIATIONS
Screen Scan Perform the Seated Flexion Test Segmental Definition Forward Torsion Right on Right (R on R) Left on Left (L on L) Backward Torsion Right on Left (R on L) Left on Right (L on R) Unilateral Sacral Flexion Unilateral Sacral Extension Bilateral Sacral Flexion Bilateral Sacral Extension R rotation on R forward torsion- L5 NSRRL
Compare and Contrast FPR and Strain Counterstrain.
Screen and Scan to locate a segment **Find the tender point associated with the segment (anterior/posterior) -Place patient into a position of comfort -**Hold for 90 seconds -Reposition without patient help -Reassess FPR -Screen, Scan and accurately Segmentally **Define a segment -Flatten lordosis/kyphosis of the spine -Add activating force -Place segment/musculature into a position of ease -**Hold for 3-5 seconds -**Reposition without patient help (important to make sure the pain is gone) -Reassess
3 steps to evaluating a patient
Screen, Scan, Segmental definition is there a problem? where is the problem? what are it's characteristics?
Upper Extremity: Screen
Screening: Two Tissue Textures Two Motion Tests At each joint Evaluate Joint Position Palpate minor motion of joints Specific Joint will be compared bilaterally Note: Unlike the axial spine, comparison of joints not above and below
Seated Flexion test What stabilizes the innominate?
Seated, the innominate is somewhat stabilized by the ischial tuberosities on the seat and flexion occurs through the spine and translated from the sacrum into the innominate via the middle transverse axis. Therefore positive seated flexion test are most likely due primarily to sacral dysfunction Sacroilial
Supplemental Exercises for Serratus
Serratus Anterior -With patient laying on their side. The elbow bent, while flexing at the shoulder. Stretch for lower fibers: inferior angle moves medially and superiorly* Upper fibers: move sup angle medially and inferiorly
Upper Extremity: Areas to Scan
Shoulder Complex (4) Sternoclavicular, Acromioclavicular, Glenohumeral, Scapulothoracic Elbow Complex (3) Radial Head, Ulnar-Humeral Joint Interosseous Membrane Wrist (3) Carpals, Metacarpals, Phalanges
Shoulder Complex: Sternoclavicular Joint Motion To Test Superior/Inferior Glide:
Shrug Test To Test Superior/Inferior Glide: Palpate superior aspect of clavicle Patient "shrugs" shoulders, then returns to neutral Normal Motion Proximal clavicle glides inferior with shoulder shrug Proximal clavicle glides superior with return to neutral Objective: Right Clavicle depressed at the SC joint with Inferior Glide Assessment: Somatic Dysfunction of the Upper Extremity
FRYETT's PRINCIPLE *I and II For a Type II non neutral dysfunction (F and E) sidebending is.... how about type I neutral dysfunction?
Side bending will be to the same side as rotation Side bending will be to the opposite side of rotation
Functional Technique- Rib Cage Positioning
Side of sidebending ease if using trunk motions And/or Upper extremity input is most often also utilized to treat a rib dysfunction
3 motions and name all 3 parts of spine you can test
Sidebend, rotate and flex/extend anterior posterior and lateral
Cool Down: Post-Treatment
Soft Tissue Linear Traction/Stretch Lower cervical muscles Posterior cervical muscles Perpendicular Stretch Bilateral Stretch OR Other treatment modalities Functional Methods FPR Muscle Energy
techniques to prepare for HVLA
Soft tissue techniques, Springing Muscle energy techniques
dysfunction trick for anterior ribs PUMP HANDLE
Space above 'Wide' (below, 'narrow') = exhalation dysfunction (resists inhalation) Space above 'Narrow' (below, 'wide' = inhalation dysfunction COMPARE RESPONSE TO EXHALATION AND INHALATION AE and NI
Diagnosis: Posterior radial head, posterior translation radius, increased carrying angle
Stabilize the humerus - done by patient position. Make contact with the proximal radius - cephalad hand; caudad hand - hand shake. Use the motions available across the joint to enhance ease. Ant/post translation, supination/pronation, compression/traction. 'Stacking' sequentially; Use respiratory ease; Eventual 'Smooth Torsion Arc'
Carpal Bones and Metacarpals treatment
Stabilize the proximal bone with proximal hand. Make contact with the distal bone with opposite hand Use the motions available across the joint to enhance ease. Med/lat & Ant/post translation, flexion/extension, compression/traction. 'Stacking' sequentially; Use respiratory ease; Eventual 'Smooth Torsion Arc'
The Functional Methods Treatment Protocol-
Stand on the side of side bending ease Start by engaging sidebending toward ease Follow with rotation toward ease Follow rotation with flexion/extension toward ease Follow with anterior/posterior translation toward ease Follow anterior/posterior translation with left/right translation toward ease. Follow with cephalad/caudad translation toward ease Each motion is refined during the respiratory ease
scan the pelvis?
Standing Flexion Test (ilio-sacral) *ASIS Compression Test
Standing Flexion test
Standing flexion occurs at the hips and is translated from the innominate into the sacrum via the middle transverse axis. Therefore a positive standing flexion test is most likely due primarily to innominate dysfunction. Iliosacral
Upslip, Right- HOW DOES THIS HAPPEN?
Step Off, Car accidents, Fall landing on buttocks Landmark findings: + Right standing flexion Iliac crest: R↑ ASIS: R↑ Pubic bone: R↑ Med Mal: R↑ PSIS: R↑ Ischial tuberosity: R↑ ST lig: lax on R
To induce extension
Straighten the lower leg Hyper flex the upper extremity
serratus strengthening
Strengthen: Keep the arm parallel to the floor. May add resistance when the patient is able. (Protracts Scapula) Semi-truck Honk Motion.
Diagnosis Review & Treatment -Scapulothoracic Jt
Stretching/ME- Hypertonic serratus anterior -Move scapula superior and slightly medial into restriction -Have pt pull scapula inferior and hold for 3-5s -Post isometric contraction reposition and repeat 3-5 times -Recheck Stretching/ME hypertonic levator scapulae or trapezius or rhomboids Place restricted muscle into restriction and have the patient move towards ease, hold 3-5s Post isometric contraction reposition and repeat 3-5 times Recheck
6. Treatment:
Suboccipital Release [new technique] Indirect: FM, FPR, Counterstrain: C1 C2 Direct: Muscle Energy
Scan: Hindfoot and Midfoot
Subtalar Inversion and Eversion at Talar Calcaneal Navicular Plantar position and tenderness Medial and inferior glide Cuboid Plantar position and tenderness Lateral and inferior glide Cuneiforms Plantar position Plantar/inferior glide Metatarsals Adduction, Abduction, Plantar, Dorsiflexion, Rotation Motion and Position
Pubic Shear- caused how?
Superior Shear More common of the two Typically caused by standing with weight unevenly distributed or by muscle imbalance Findings: + standing flexion test Ipsilateral pubic bone superior +/- Tension and tenderness of ipsilateral inguinal lig.
Transverse Axes
Superior: Respiratory and Craniosacral axis Located at approximately S2, at the location of dural attachment Middle: Postural axis Bilateral Flexion & Extension occur around this axis Inferior: Innominate rotation axis
ankle motions
Supination Equivalent Inversion Plantar Flexion Adduction Pronation Equivalent Eversion Dorsiflexion Abduction
motion testing
Supine Standing Seated
SUPERIOR THORACIC APERTURE- steering wheel- SUPINE RELEASE
Supine Diagnosis & Treatment: Thumbs go posteriorly: contact costo-transverse junction bilaterally (this allows control of T1 and the first ribs) Fingers wrap around the neck: the finger pads come as close to the junction of the first rib and manubrium as possible (this means the finger is looping over the clavicle.) Gently try to rotate the superior thoracic aperture left & right to the 'feather edge of resistance' Which direction is easier? (like screening) Gently side bend left & right Which direction is easier? Treatment: carry the sup. thor. Aperture in both directions of ease
documentation for functional methods T6- flexed rotated sidebent right translated posterior left and superior and inhalaiton
T 6: FRSr, Tran PLS, Inh
Rule of Threeesss
T1-3: TP at the same level as the tip of the SP T4-6: TP ½ vertebral level above the tip of the SP T7-9: TP 1 full vertebral level above the tip of the SP T10: TP 1 full vertebral level above the tip of the SP T11: TP ½ vertebral level above the tip of the SP T12: TP at the same level as the tip of the SP
Alternate Method for Upper Thorax
T3 ER(L)S(L) -Prone position flattens thoracic kyphosis -Stand opposite the dysfunction -Place your finger on posterior TP of T3 -Grasp pt's shoulder with caudad hand -Pull shoulder toward pt's feet to induce sidebending -Maintaining force pull pt's shoulder backward off the -table creating left rotation -Hold for 3-5 sec -Recheck
Red Reflex description of findings
T5 FRrSr: red reflex lingers after tissues above and below blanch out; right paraspinal muscles at this level are tender.
Thoracic Segmental Somatic Dysfunction/ Deep Muscles:
T7 ER(L)S(L) -Pt seated -Finger on posterior transverse process -Forearm on pt's left shoulder and behind neck -Instruct pt to sit up straight to flatten kyphosis -Add compressive force down to T7 -Extend through level of T7 -Sidebend and rotate left to maximal ease -Hold 3-5 seconds -Slowly return to neutral -Recheck
scanning
TART -tissue texture abnormalities -asymmetries -restriction to motion -tenderness or STAR -sensitivity changes instead of tenderness
Stretches summary
TIPS! If the neck is hypertonic do something else first Finding the Barrier Don't lose barrier when pt takes a breath Patient relaxation! Engage resistance slowly and actually feel what you need to Locking out the segment Thrust
How do you screen the pelvis?
TISSUE TEXTURE -Lateral Posterior Gluteal Tissue -Sacral Tissue MOTION -Lateral Translation -Pelvic Rotation
Functional Anatomy: Subtalar Joint
Talocalcaneal Joint Secondary glide motions are Inversion Eversion Also Talonavicular glides Anteromedial (eversion) Posterolateral (inversion)
Abductors NAME SOME Testing End Range & Strength Against Resistance
Tensor Fascia Lata Gluteus maximus medius minimus All attach somewhere on the ilium All 3 have a role in extending the hip
Lateral Translation
Test for SB mobility Passively move superior vertebrae Translation = Opposite SB
first degrees of motion significance?
The first few degrees of motion are most critical Need to remind patient to remain passive and not help If they start to help, stop moving, ask them to relax again, wait for relaxation, and begin moving
Mechanics of the lumbar spine
The lumbar spine (L5) and the sacrum move in opposite directions.
term to describe the addition of motions, when do you refine the motions
The order and the process of placing all six motions into its ease has been termed 'Stacking' Each motion is refined during the respiratory phase of ease -Ride the phase of *respiratory resistance* maintaining as much ease as possible*
What is the mobile unit?
The relationships between the segment of interest and the segments above and below (3 segments) The Mobile Unit is not comprised of just bony elements. It includes the connective tissue and neuromuscular elements such as: Proprioceptive and Nociceptive Sensory feedback that provide input to the brain.
When is activating force added : before or after putting the segment into ease
The sequence can be varied depending on the skill and experience of the physician
Making a Pelvic Diagnosis
The standing flexion test was the scan of the pelvis Checking landmarks is how you segmentally define the pelvis Record your findings at each landmark with respect to the side of the (+) standing flexion test Example: (+) standing flexion test on the R If you find that the L iliac crest is higher than the R, record that the R iliac crest is lower Record what the side of (+) standing flexion test is doing! This makes your diagnosis much easier at the end Put all the pieces together to make a diagnosis R Anterior Innominate, L Superior Pubic Shear, etc.
Thoracic anatomy
Thoracic vertebra slightly larger vertebral bodies than the cervicals, and increase in size as they become more weight bearing Angle of the articular facets about 60 degrees from the horizontal plane
ASIS segmental definition: name a motion test too
Thumbs immediately inferior to both bony prominences A/P; S/I; closer or further away from belly button (I/E) Motion (supplemental) Compression test. Ease of motion in the A/P planes is noted with alternating, rocking pressure
Hip Flexion Testing and Restriction Treatment : (Hip Extensor Tightness)
Tightness at End-Range: Keep the knee bent a few degrees; that protects it.
testing 8 regions
Tissue Texture and Motion Symmetry allow examiner to assess regional responses independently
Scapulothoracic Joint Protraction- Assess Pectoralis Minor AND TREATMENT
To Assess Pectoralis Minor: -Contact insertion of pectoralis minor at ribs 3-5 -Abduct ipsalateral upper extremity while palpating insertion of pectoralis minor -Compare ROM of pectoralis minor bilaterally Muscle Energy- Hypertonic Pec Minor Abduct extremity until restriction (~120-130º) is palpated in the pec minor Have the patient adduct for 3-5s Reposition into restriction and repeat 3-5 times Recheck Note: Can be performed seated or supine
To Assess Serratus Anterior:
To Assess Serratus Anterior: -Patient is lateral recumbant -Contact lateral edge of scapula with thumb and thenar eminence of caudad hand -Cephaland hand grasps superior portion of scapula -Test motion medially and superiorly
motion testing for AC joint=To Palpate Internal/External Rotation:
To Palpate Internal/External Rotation: =Palpate AC joint same as previous slide =Bring upper extremity to 90° =Grasp wrist and externally rotate, while palpating for restriction at AC joint Wrap arm under patient's arm and grasp wrist, internally rotate while palpating for restriction at AC joint Example: Objective: Right AC Joint positive stair-step, abducted and externally rotated Assessment: Somatic Dysfunction of the Upper Extremity
testing sternoclavicular joint
To Palpate Proximal Clavicular Position: Physician Behind Patient Thumbs on superior portion of proximal clavicle bilaterally Assess for superior/inferior position Fingers placed on anterior surface of clavicle bilaterally Assess anterior/posterior position Note: can be performed seated or supine
Shoulder Complex: Sternoclavicular Joint Motion To Test Anterior/Posterior Glide:
To Test Anterior/Posterior Glide: Palpate anterior aspect of clavicle Patient adducts and flexes shoulder to 90° Patient reaches forward, then returns to neutral Normal Motion: As patient reaches forward, clavicle glides posterior Return to neutral, clavicle glides anterior Ex: Objective findings: Right clavicle anterior at SC joint with Anterior Glide Assessment: Somatic Dysfunction of the Upper Extremity
motion testing for AC joint- To Test for Abduction vs Adduction:
To Test for Abduction vs Adduction: Midde finger on distal clavicle Index finger on acromion Passively abduct arm while palpating AC joint Palpate joint for restriction of motion and compare bilaterally
goal of ME
To decrease Muscle Hypertonicity To lengthen muscle fibers To reduce the restrained movement To strengthen weaker muscles To allow for greater joint mobilization
Translating rule + testing
Translation Testing Translation towards the R = Sidebending L Palpate for restriction Resists translation to the L --> Sidebent R reistance --> Sidebent L ease Place index fingers on articular pillars Translate L and R - feel for restriction Repeat in flexion and extension Remember, lesions will translate more symmetrically in their (flexion/extension) position of ease Practice this while standing too!
Lumbar Treatment Sequence
Treat Non-neutral (F/E) Type II First Then treat Neutral (Group) Type I Dysfunctions Logic: Presence of Type II dysfunctions result in compensatory Type I dysfunctions
3. Cervico-Thoracic Junction [Superior Thoracic Aperture] treatment
Treatment 1st Rib: Indirect: Counterstrain, FPR, FM Direct: Muscle Energy Superior Thoracic Aperture Supine release [new technique]- STEERING WHEEL Anterior cervical fascia release—seated [new technique]- choke hold
rib disengaging
Treatment augmentation by disengaging the rib head posteriorly is helpful when possible
OA: Flexed side bent right rotated left
Treatment: Left Hand contacts left occiput at AO articulation Right Hand cradles the head and neck. Goal: Carry the left occiput forward on the atlas - toward the opposite orbit Patient Relaxation: 'Take a deep breath in, then let it out slowly.' 'Let your head drop toward the table.' Dx: FSrRl
Dysfunction: Posterior Fibular Head
Treatment: Direct Articular Flex knee External rotation of tibia MCP or thumb posterior to fibular head Flex to resistance Spring flexion of knee to encourage fibular head anterior Treatment: Direct Muscle Energy Seated position Thumb and finger grasp fibular head Dorsiflexion of ankle to resistance (encourages eversion, pronation, external tibial rotation, anterior proximal fibula) Isometric contraction plantarflexion Repeat
Dysfunction: Anterior Fibular Head
Treatment: Direct Articular (Supine) Flex knee slightly Internal rotation of tibia Thumb over fibular head, opposite hand stabilizes lateral malleolus Rapid extension of knee Encourage posterior movement of fibula Treatment: Direct Muscle Energy Seated position Thumb over fibular head directing posterior Plantar flexion of ankle to resistance (encourages inversion, supination, internal tibial rotation, posterior proximal fibula) Isometric contraction dorsiflexion Repeat
put hand under what and patient supine
UNDER transverse process
C3-7 Uncovertebral Joints
Uncinate process- lateral ridge (lip) along superior surface of bodies of C3-7 Posterolateral corner vertebral bodies Function in gliding movements -F/E-guide vertebral body motion -R and SB-Limit lateral translation Protect disc from posterolateral herniation Osteoarthritis side: Osteoarthritis-lipping- enchroaches on anterior aspect of lateral intervertebral canal and affect spinal nerves
Functional Technique- Upper Extremity & Rib Function
Upper Extremity Motion Input Assess for asymmetric response (ease/bind) at the rib angle. Motions: Abduction/Adduction External/Internal Rotation Cephalad/Caudad Compression
Upper Extremity Influence Upon Rib Function
Upper Extremity Motion Input: Assess for asymmetric response (ease/bind) at the rib angle. Motions: Abduction/Adduction External/Internal Rotation Cephalad/Caudad Compression ALSO A COMPLETE MOTOR ASYMMETRY - FOR UPPER EXTREMITY
Upper half #3
Upper picture shows combination of Levator and Pec How can this be modified to a ME treatment!?
pump handle? bucket handle? calipers? how to assess each?
Upper ribs ( 1-6 pump handle ) - ASSESS ANTERIOR AND POSTERIOR = increase in anterior and posterior diameter Lower ribs (7-10 bucket handle - ASSESS LATERAL SIDE (increase in transverse diameter) 11-12 caliper motion)- slight increase in transverse and AP diameter -------IF MIXED middle ribs- can be ant/post/transverse
4. Thoracic/Other Ribs
Upper thoracics provide sympathetic innervation to viscera above the diaphragm Heart, Lungs, Head and Neck Upper thoracic regions provides important biomechanical relationships to cervical spine, thoracic inlet, ribs and associated scapulothoracic joint A Non-Neutral in the T4-6 area is not uncommon. Correlate with Sympathetic innervations and associated viscera. autonomic nerves and intercostals *
Left on Left (ROTATION ON ___ AXIS) Right on Right
WHEN SAME- FORWARD WHEN OPPOSITE- BACKWARDS
Concentric Isotonic
When the muscle tension causes the origin and insertion to approximate
What is happening during the treatment?
With a bilaterally extended sacrum, the sacrum prefers extension As the patient extends the trunk, the sacrum is forced into flexion This is the restricted barrier Then, as the patient flexes, the sacrum starts to extend bilaterally The physician uses a counterforce at the sacral base to prevent sacral extension. As the patient relaxes, the patient can further extend the trunk and cause an increase in sacral flexion
What is happening during treatment?Left Unilateral Flexed Sacrum
With left unilateral flexed sacrum, the sacral sulcus is anterior and the ILA is posterior. The left leg is abducted and internally rotated to gap SI joint to allow for movement of sacrum Anterior, superior pressure at left ILA causes the left side of sacrum to extend (into its restrictive barrier) Patient augments this by inhaling this causes increased sacral extension at the base Pressure at the left ILA during exhalation (between held inhalations) prevents the sacrum from flexing Low Velocity, Moderate Amplitude (LVMA) springing could be used to augment this treatment.
What is happening during treatment?
With patient supine and the hips rotated with the axis down... L5 rotation occurs to the right causing sacral motion to the left (motion that is restricted) Furthermore... Extension of the left leg during treatment positioning causes further flexion of sacrum (i.e. restrictive barrier of sacrum) With ME, the patient is activating the piriformis and is also engaging the ligaments around the sacral pelvic region to allow for sacral rotation For backwards torsion...Lay patient on their "Back" Remember, axis down on the table!
LATERAL POSTERIOR T5-T12
abuduct arm, turn head ipsilateral, side-bend trunk away from tender side
lymphatic drainage
all the techniques, local , acute, to draw fluid DISTAL TO PROXIMAL towards thoracic duct!
anterior versus posterior rib adjustment
anterior rib (exhalation- push on front) posterior (inhalation)- in both treatments, stand behind patient
what important thing do you do while you monitor and before you position a patient
apply the downward force-
position of arm for rib adjustment
arm over cervicothoracic junction, and elbow over acromion
how to define inhalation and exhalation
ask patient to sit up straight and drop shoulders
Piriformis
b/w PSIS and coccyx (midway) -flex same side hip 135 degrees and laterally rotate (especially if tenderness is lateral)
lymphatic congestion
breathing in with compression to allow for fluid drainage- release quickly
ribs 1-10 can have what kind of mechanics
bucket or pump AND inhalation or exhalation
inhibition
deep pressure
treament HVLA 4 steps and WHAT IS THE MOST IMPORTANT THING TO DO
diagnose, prepare, localize, thrust - prepare patient and have them relax*****
primary muscle of respiration
diaphragm
traction
drawing structures apart
most posterior on L side=
ease side
attention on motions of the ribs at the ...
end range of inhalation and exhalation
treatment of exhalation or inhalation disfunction
exhalation dysfunction- move ribs into inhalation inhalation dysfunction- move ribs into exhalation
Sacrum
find tenderpoint and press as far from tenderpoint as possible
(Anterior) Depressed Ribs 1&2
flex neck, rotate towards bad side, and side-bend towards
effleurage
helps fluids move along lymphatic channels
where do you put specific dysfunction
in OBJECTIVE *just right somatic dysfunction in assessment
levator scapulae
inferior attachement of muscle at levator scapulae, pull arm back to rotate scapula medially. push scapula up to head -head should be on pillow to assist in side-bending
primary motion of rib cage
inhalation and exhalation- also exhibits the others-
exceptions to passive motion
jaw, costal cartilage, and lumbar spine
name 5 ways to address soft tissue issues
kneading traction inhibition petrisage effleurage
one hand is always*
listening
traction
longitudinal stretch
muscles that attach to thoracic vertebrae
longus colli, serratus posterior, erector spinae and transversospinalis SHORT: levator costarum, intertransversarii, and interspinalis muscles
Iliacus
medial from ASIS by 7 cm -flexion of hips -lateral rotation of hips -knees abducted
define passive motion
minimal force to initiate motion
Somatic dysfunction of knee
minor motions: -anterior posterior glide -medial/lateral glide -anteromedial or posterolateral glide (associated with int/ext rotation)
lumbar ME-
more rotational forces are needed to localize down to the segment More Side Bending, Rotation, and/or Flex/Ext might be required Recall Fryette's Law III
Scan (confirms what?)
motion scan and uses deep pressure
posterior elevated rib 1!
neck extend and side-bent away and rotate to tender point
Listening and Motor Hand
one hand feels (segment of interest) and one hand moves
choke points
open from central to peripheral so appropriate drainage can take place
upper ribs inspiration
place hands above clavicle, over ribs and feel exhalation
when to use these soft tissue techniques?
prep for other techniques reduce adhesions, hypertonicity applicable to any part of body
testing while prone
push down on either side = rotation lift transverse process up and down= flexion extension above on one side and below on the other= sidebending
if no change in flexion or extension=
remains neutral more than one segment may be involved
Upper extremity muscles
rhomboids, latissimus dorsi and trapezius
kneading
rhythmic lateral stretching, force applide perpendicular to muscle axis
Exhalation restriction
rib will stop moving down before the "normal" rib on the other side
Restricted inhalation
rib will stop moving up before contralateral rib on attempted full inhalation
anterior rotation loosens what ligament
sacrotuberous
3 components of diagnosis process
screen scan segmental definition (is there one, where is it, what is it?)
With Bilateral Sacral Flexion or Extension
seated flexion test is Falsely Negative and the Sacral Sulci appear equal in depth.** Therefore, another diagnostic modality must be used The Spring Test SPHINX TEST
START
sensitivity tissue texture asymmetry range of motion deficit tenderness
(Posterior) Elevated Rib 2-6
side-bend away from tender point, to elevate rib, CONTRALATERAL arm behind back, ipsilateral arm is abducted and supported by physician thigh
in scan u perform one motion scan to confirm (MUSCLE ENERGY)
sidebending OR rotation
We will focus on these 2 types of passive motion testing for the spine
sidebending and rotation --> LOOK FOR THE IMMEDIATE RESPONSE!!! Any further and it is a diff test.
most effective position to treatment for muscle energy
sidebending has been determined by Dr. Mitchell and his team to be the most effective.
You should pay attention to which direction resistance is encountered ________________
sooner
Rotation test of thoracic vertebra
stand behind and to the side. Put hand on spot (listening hand) and rotate left and right (with other hand on elbow)
tissue texture
standing
Tapotment
start at hypothenar ridge and down, rapid massage to increase tone and arterial profusion
inhibition
steady deep pressure applied, broad or precise. TRIGGER points- nodules, tender points that do not radiate! -suboccipital release- prone (may do traction and kneading before-hand)
rules
strokes to heart, broad strokes, encourage deep breathing
objective
succinct musculoskeletal findings
lower ribs inspiration (LOWER)
supine feel near margins and feel for resistance
SOAP NOTES - subjective
unique historical elements related to musculoskeletal system
places to feel for resistance to pressure
upper and lower 3 regions, lateral limbs, anterior ribs
gluteus medius
upper outer portion of gluteus medius -extend hip, abduction and lateral rotation
What if the Motion scan does not yield mirror image asymmetry?
where above and below are not opposite to middle vertebra. You expand the tile to the motion tested location. Then you confirm with another motion test.
where do you find dysfunction
where you find a bump OR sudden decrease, It is not acting in concert with tissue around it. It is OUT OF STEP. We check above and below segment and look for asymmetry. So the bad vertebra has actions OPPOSITE on the vertebra above and below it.