OMM Block 2

Rib HVLA (3rd edition p. 381-386) Rib 1-2 seated

' captn morgan pose' - put your *leg opposite side of dysfunction* up on the table lean pt into leg (they should not be sitting up straight!) and have them drape arm over leg (so knee is in armpit) put your metacarpal phalangeal joint on side of dysfunction on center shoulder use your other hand *stabilize the head & sidebend it toward the dysfunction, rotate away* have pt take deep breath in and out (make sure their shoulder on side of dysfunction is relaxed/dropped) on exhale, use hand on shoulder to thrust down (vector is oblique like a seatbelt) --table height must be correct so you can thrust down -- pt needs to be very close to body to achieve thrust

Pt position & target muscle for treating an exhaled rib 2 with muscle energy

'southern belle' but rotate away from hand posterior scalene

Pt position & target muscle for treating an exhaled rib 1 with muscle energy

'southern belle' pose anterior/middle scalenes

ribs 11-12 inhalation HVLA (p. 370)

'wringing technique' caudad hand holds ASIS opposite hand thenar eminance is on the rib angle ('cup' bottom ribs) side bend pt's legs away from you to isolate the ribs (optional) you are trying to push ribs up and in bc he is stuck down and out superior hand is going to thrust down while ASIS hand pulls up -- it is a very quick thrust on exhalation bring pt's legs back to neutral & reassess

pecten pubis

(part of linea terminalis, along with pubic crest & arcuate line)

mnemonic for treating exhalation dysfunctions

*ETD* *E*xhalation *T*reat the *t*op rib *D* ribs caught *'D*own'

mnemonic for treating inhalation dysfunctions

*I* *L*ove *U* *I*nhalation *L* treat the *l*owest rib *U* ribs are caught '*U*p'

What is the unilateral action of the scalenes?

*S*idebend *sa*me side, rotate same side

attachments, action, innervation of scalenes

*anterior* attaches TP C3-6 & 1st rib *middle* attaches TP C3-7 & 1st rib *posterior* attaches TP C5-7 & 2nd rib *action*: raises upper ribs in inspiration *innervation*: cervical/brachial plexus (C3-6)

Diaphragm: attachments- insertion - innervation-

*attachments*- ribs 7-12 bilaterally; L1-3 vertebral bodies/IVDs; xiphoid process *insertion* - central tendon *innervation*- phrenic nerve (C3-5)

sternocleidomastoid origin insertion action innervation

*origin*: manubrium, medial 3rd of clavicle *insert*: mastoid process, post nuchal line *action*: unilateral- sidebend toward/rotate away bilateral- extends head, assists in respiration *innervate*: accessory nerve

subclavian nerve

-branch from the superior trunk of brachial plexus -supplies the subclavius muscle -1 of 2 nerves to arise from superior trunk (the other is the suprascapular nerve)

Lumbar lateral recumbent type 1 dysfunction (radiculitis) HVLA - pg. 374

1. Pt in R lateral recumbent position; Dr stands facing pt 2. Dr palpates between pt's sp processes of L5-S1 & flexes pt's hips/knees until L5 is fully flexed in relation to S1 3. Dr positions pt's L leg so that it drops over side of table 4. While continuing to palpate L5, Dr places cephalad handin pt's L antecubital fossa while resting forearm on pt's shoulder 5. Dr places caudad forearm in line between pt's PSIS & greater trochanter 6. Dr's arms move apart to introduce a separation of L5/S1 on L. This causes distraction (joint gapping) of L5/S1 7. Pt, relaxed/not guarding, inhales & exhales. During exhalation Dr delivers impulse that separates L5/S1 without permitting rotation/torsion 8. Reassess severity of radicular symptoms

lumbar soft tissue lateral recumbent position (p. 110)

1. Pt in lateral recumbent position with treatment side up, Dr stands on side facing front of pt 2. Pt's knees/hips flexed, Dr's thigh against pt's infrapatellar region 3. Reach over pt's back, place pads of fingers on medial aspect of paravertebral muscles overlying lumbar T processes 4. Gentle force ventrally/laterally to create perpendicular stretch 5. Dr's thigh against pt's knees may be used for bracing, or flexed to provide combined bowstring/longitudinal traction force on paravertebral muscles 6. Gentle/rhythmic/kneading fashion or deep sustained pressure 7. may modify by bracing ASIS with caudad hand while drawing paravertebral muscles ventrally with cephalad hand 8. Reposition to contact diff levels of lumbar spine, repeat 9. Reassess

Lateral recumbent muscle energy for lumbar type 1 dysfunction (post isometric relaxation) - p. 276

1. Pt lies in R lateral recumbent position on side of rotational component of dysfxn while Dr stands at side of table facing pt 2. Dr's caudad hand or thigh controls pt's flexed knees/hips while cephalad hand palpates sp processes of dysfxn 3. Dr's caudad hand/thigh gently flexes/extends pt's hips until Dr's cephalad hand determines dysfxnal segment to be positioned in neutral 4. Pt's left leg is lowered off edge of table, causing anterior rotation of pelvis, until Dr's cephalad hand detects motion at dysfxnal segment 5. Switching hands, Dr uses cephalad hand to gently move pt's shoulder posteriorly until caudad hand detects motion at dysfxnal segment 6. Dr tells pt to gently push shoulder forward while Dr's cephalad hand applies counterforce. 7. Isometric contraction held 3-5secs 8. Once relaxed, Dr moves pt's shoulder posteriorly, rotating thoracic/lumbar spine to edge of new restrictive barrier 9. Pt told to gently pull hip & pelvis cephalad, up toward shoulder, while Dr's caudad hand applies counterforce. 10. Hold 3-5 secs 11. Once pt is relaxed, Dr moves pt's pelvis caudad to edge of new restrictive barrier 12. Repeat 3-5x; reassess

Lateral recumbent muscle energy for lumbar type 2 dysfunction (post isometric relaxation) - p. 278

1. Pt lies in R lateral recumbent position on side of rotational component of dysfxn while Dr stands facing pt 2. Dr's caudad hand or thigh controls pt's flexed knees/hips while cephalad hand palpates sp processes of dysfxn 3. Dr's caudad hand/thigh gently flexes/extends pt's hips until Dr's cephalad hand determines dysfxnal segment to be positioned in neutral 4. Dr's caudad hand places pt's left foot behind right knee in popliteal fossa 5. Switching hands, Dr uses cephalad hand to gently move pt's shoulder posteriorly until caudad hand detects motion at dysfxnal segment 6. Tell pt to gently push shoulder forward against Dr's cephalad hand, which applies counterforce. 7. Hold 3-5secs 8. Once pt is relaxed, Dr moves pt's shoulder posteriorly, rotating thoracic/lumbar spine to edge of new restrictive barrier 9. Pt gently pushes hip/pelvis backward against counterforce of Dr's caudad hand 10. Hold 3-5secs 11. Repeat 3-5x; reassess

Lumbar lateral recumbent type 2 dysfunction HVLA - pg. 372

1. Pt lies in R lateral recumbent position with Dr standing facing pt 2. Dr palpates between sp processes of L5 & S1 & flexes pt's knees & hips until L5 is in neutral position relative to S1 3. Dr further positions pt's L leg so it drops over side of table cephalad to R leg. Pt's foot must not touch floor 4. While palpating L5, Dr places cephalad hand in pt's left antecubital fossa while resting forearm gently on pt's anterior pectoral & shoulder region 5. Dr places caudad forearm along line between pt's PSIS & greater trochanter 6. Pt's pelvis rotated anteriorly to edge of restrictive barrier; pt's shoulder/thoracic spine rotated posteriorly to edge of restrictive barrier. Pt inhales & exhales 7. If rotational slack or motion barrier is not effectively met, Dr can grasp pt's R arm, drawing shoulder forward until rotational movement is palpated between L5/S1 8. With pt relaxed/not guarded, Dr delivers impulse thrust with caudad forearm directed at *right angles to pt's spine* while simultaneously *moving shoulder slightly cephalad & pelvis/sacrum caudad*to impart sidebending R & rotation L 9. Reassess intersegmental motion at level of dysfxnal segment

Supine Lumbar Walk-Around (HVLA) - pg. 375 "Chicago Roll"

1. Pt lies supine with both hands behind neck/fingers interlaced 2. Dr stands at head of table to pt's R & slides R forearm thru space created by pt's flexed R arm/shoulder 3. Dorsal aspect of Dr's hand placed at pt's midsternum 4. Dr walks to head of table to L side 5. While palpating posteriorly with caudad hand, Dr sidebends pt's trunk to R until dysfxnal segment moves 6. Dr begins to rotate pt to L while maintaining original sidebending 7. Dr's caudad hand anchors pt's pelvis by placing palm on pt's R ASIS 8. With pt relaxed/not guarding, Dr directs impulse that pulls pt minimally into further L rotation 9. Reassess intersegmental motion at level of dysfxnal segment

lumbar prone pressure (p. 105)

1. Pt prone - Dr stands opposite of side to be treated 2. Place thumb/thenar eminence over T processes on side opposite Dr 3. Place thenar eminence of other hand on top of abducted thumb of bottom hand 4. With elbows straight, gentle *ventral force* to engage soft tissues *& laterally perpendicular* to lumbar paravertebral musculature 5. Hold force several secs, release. Repeat several times - reposition to contact different levels of lumbar spine - 30-60 secs total 6. May also use deep, sustained pressure 7. Reassess

Lumbar prone pressure with counterleverage (p. 109)

1. Pt prone, Dr on opposite side of that to be treated 2. Thumb/thenar eminence of cephalad hand on medial aspect of paravertebral muscles overlying lumbar T processes on side opposite Dr 3. Caudad hand contacts pt's ASIS on side to be treated; gently lift it up 4. Cephalad hand exerts gentle force ventrally/laterally, perpendicular to lumbar paravertebral musculature 5. Force held several secs, slowly release; repeat in slow/rhythmic/kneading fashion or deep sustained pressure 6. Cephalad hand repositioned to different levels of lumbar spine, repeat 7. Reassess

lumbar bilateral thumb pressure, prone (p. 107)

1. Pt prone, Dr stands at side of table at level of pt's thighs/knees 2. Dr's thumbs on both sides of spine, contacting paravertebral muscles overlying T processes of L5 with fingers fanned out laterally 3. Thumbs exert gentle force ventrally, engaging soft tissues cephalad & laterally until barrier/limit reached 4. Hold stretch for several secs, slowly release & repeat in gentle/rhythmic/kneading fashion (or deep sustained pressure) 5. Thumbs repositioned over T processes of L4, L3, L2, L1; repeat 7. Reassess

Lumbar prone, scissor technique

1. Pt prone, Dr stands side opposite that to be treated 2. On side to be treated, caudad hand reaches to grasp pt's leg proximal to knee/tibial tuberosity 3. Dr lifts leg, extending hip/adducting it toward other leg to produce scissors effect 4. Caudad hand may be placed under far leg then over proximal leg so that leg can support dr's forearm 5. Dr places thumb/thenar eminence of cephalad hand on pt's paravertebral musculature overlying lumbar T processes, gentle ventral/lateral force to engage soft tissues 7. hold force several secs, repeat in slow/kneading technique or deep sustained pressure, go up lumbar spine, 30-60 secs total 8. reassess

Lumbar prone traction (p. 106)

1. Pt prone. Dr stands at side of table at level of pt's pelvis 2. Heel of cephalad hand placed over base of sacrum, fingers pointed toward coccyx 3. Caudad hand placed over lumbar spinous processes with fingers pointing cephalad, contacting paravertebral soft tissues with thenar & hypothenar eminences -- or place hand to side of spine contacting paravertebral musculature 4. Exert gentle force with both hands ventrally to engage soft tissues, creating separation/distraction effect (do not push down on spinous processes) 5. Apply technique in gently, rhythmic, kneading fashion or deep, sustained pressure 6. Caudad hand repositioned at other levels of lumbar spine, repeat > 30-60 secs total 7. Reassess

lumbar myofascial release (p. 113) - paravertebral muscle spasm/myofascial hypertonicity

1. Pt seated at end of table with Dr standing behind and to side opposite dysfunction 2. Pt places hand opposite Dr behind neck, other hand grasps that elbow. Dr reaches under pt's axilla & grasps pt's upper arm 3. Dr's thumb/thenar eminence placed on medial aspect of paravertebral muculature opposite Dr, overlying lumbar T processes 4. Pt leans forward/relaxes/allows body weight to rest on Dr's arm 5. Dr directs gentle ventral/lateral force to create perpendicular stretch while rotating pt with other arm/hand 6. Hold stretch for several secs, repeat in gently/rhythmic/kneading fashion or deep sustained pressure 7. Reassess

Seated muscle energy for lumbar type 1 dysfunction (post isometric relaxation) - pg 272

1. Pt seated; Dr stands opposite rotational component of dysfunction 2. Pt places R hand behind neck & L hand on R elbow 3. Dr passes L arm under pt's L arm & grasps pt's R upper arm 4. Dr's R hand monitors sp processes of dysfunction as the L arm & hand flex/extend pt's torso until the more inferior vertebra is neutral in relation to the superior vertebra 5. Dr's R hand monitors T processes of dysfxn to localize sidebending & rotation as L arm & hand position in pt's torso to edge of R sidebending, then L rotation barrier 6. Dr instructs pt to turn or pull R shoulder back to R while dr's L hand applies counterforce. 7. Isometric contraction held 3-5 secs; pt told to stop & relax 8. Repeat 3-5x; reassess

Seated muscle energy for lumbar type 2 dysfunction (post isometric relaxation) - pg 274

1. Pt seated; Dr stands opposite rotational component of dysfunction 2. Pt places R hand behind neck & L hand on R elbow 3. Dr passes L arm under pt's L arm & grasps pt's R upper arm 4. Dr's R hand monitors sp processes of dysfunction to localize flexion/extension as the L hand positions pt's trunk to edge of restrictive flexion barrier 5. Dr's R hand monitors T processes of dysfxn to localize sidebending & rotation as L hand positions pt's trunk to edge of L sidebending, then L rotation barriers 6. Dr instructs pt to sit up & gently pull R shoulder backward while Dr's L hand applies counterforce. 7. Isometric contraction held 3-5 secs; pt told to stop & relax 8. Repeat 3-5x; reassess

Lumbar muscle energy

1. Pt supine 2. Sit same side being treated 3. Place pads of fingers under back on paravertebral musculature, pull ventrally/laterally. Hold for several secs, move up lumbar spine - 30-60 secs total 4. Reassess

typical ribs

3-9 have *head, tubercle, neck & angle*

radiology of the lumbar spine

AP view - note L5 with its larger T processes lateral view - note large flat T processes of lumbar vertebrae, which allow for muscular attachments

What is the origin of the anterior scalene?

C3-C6 anterior transverse processes

thoracodorsal nerve is composed of what?

C6-8

blurb for muscle energy

Direct & active technique Pt is resisting counterforce given by Dr in order to relax hypertonic muscle or ↑ joint mobility in restricted joint. Post isometric relaxation - Dr's contracting counterforce places ↑ tension on Golgi tendon organ's proprioceptors within pt's contracting muscle's tendon. ↑ tension on Golgi tendon organ causes reflex inhibition after pt stops contracting & subsequent ↑ in muscle length within hypertonic muscle.

blurb for soft tissue techniques

Direct technique Involves kneading, stretching, deep pressure, inhibition, and/or traction, while monitoring tissue response & motion changes by palpation Form of myofascial treatment

Fryette's 1st law of motion

Group dysfunction Neutral (due to neutral position of facet joints) When thoracic & lumbar spine are in neutral position, coupled motion of SB & R for a group of vertebrae occur to opposite sides

How to diagnose rib dysfunction

Have pt seated or supine Palpate between clavicle & traps (for 1st rib), check to see if symmetrical in inspiration/expiration -- should rise & fall to same degree For other ribs, do the same

aspects of IVDs and posterior longitudinal ligament of lumbar spine

IVDs are largest compared with other parts of spine posterior longitudinal ligament is continuous with IVDs

Fryette's 3rd law of motion (actually described by CR Nelson, DO in 1948)

Initiating motion in a vertebral segment in 1 plane will modify the motion of that segment in other planes

Intersegmental motion

Note multifidus origin at T processes of lumbar spine, and asymmetric insertion at spinous process at a superior vertebra

Inhalation dysfunction: Rib 1-2 post-isometric relaxation

Pt lying supine Sit behind head Place hand on restriction Other hand on head, sidebend toward/rotate away Have pt try to lift head -- will contract scalenes

Inhalation dysfunction: ribs 11-12 respiratory assist

Pt prone Put one hand on ASIS, other hand pulls the other way Have pt breathe in & out as you resist

Inhalation dysfunction: Rib 1-2 seated respiratory assist (p. 366)

Pt seated Stand behind them with hand on dysfunctional rib (or key lesion if grouped) Put knee on side opposite dysfunction Place other hand on head, sidebend them toward, rotate them away from dysfunction to engage scalene Have pt breathe deeply in & out 5-7x Hand on dysfunction holds it down while pt is breathing

Inhalation dysfunction: Rib 2-6 supine respiratory assist

Pt supine Place knee beneath affected side Place MCP on dysfunction Resist inhalation by pressing down as pt tries to inhale

Inhalation dysfunction: Rib 7-10 supine respiratory assist

Pt supine Sit on affected side with thumb on lowest rib in group Keep pressed down as pt inhales deeply in-out 5-7x Reassess by placing hands on either side to assess ribs on both sides during respiration

Fryette's 2nd law of motion

Single- Non-neutral - Same side

Side to stand on for exhalation ME ribs 6-8

Stand same side

QL is innervated by what?

T12-L4 ventral ramus

relative contraindications for soft tissue

acute injury (fasciitis, fracture, tears, burns) infection neoplasm blood disorders

rib motion is influenced by what?

angle b/t vertebral body & transverse process & distance b/t costal articulations

main ligament that provides support to anterior aspect of spine

anterior longitudinal ligament (spans pretty much entire width of vertebral body)

origin of pec minor

anterior superior surface of ribs 3-5

lateral pectoral nerve

anterior to axillary artery arises from lateral cord of brachial plexus passes medial to pec minor to supply sternoclavicular head of pec major communicates with medial pectoral nerve

external intercostals origin- insertion- fxn in respiration - innervation-

arise lower margin of rib insert on upper margin of next lower rib raise ribs in inspiration 1-11 intercostal nerves

internal intercostals origin- insertion- fxn in respiration - innervation-

arise upper margin of rib insert of lower margin of next higher rib lower ribs on expiration 1-11 intercostal nerves

long thoracic nerve

arises from 5th, 6th, 7th ventral primary rami of brachial plexus supplies serratus anterior lesions of this nerve result in winging of scapula

medial pectoral nerve

arises from medial cord of brachial plexus - pierces the pectoralis minor & continues to supply the sternocostal head of pec major - communicates with lateral pectoral nerve

Pt position & target muscle for treating exhaled ribs 6-10 with muscle energy

arm extended anterior serratus

Why doesn't the spine have as much stability in flexion as it does in extension?

bc posterior longitudinal ligament (continuous with IVDs) has far less width than anterior longitudinal ligament (spans most of vertebral body width -- that's why you're able to flex much further than you're able to extend, bc the anterior long. lig. prevents too much extension

insertion of latissimus

bicipital groove of humerus

bucket handle rib motion

both ends fix, increases transverse diameter *mixed pump & bucket handle motion for ribs 1-10; lower ribs have more bucket motion (you go *down* to kick the *bucket*)

What is deep to the pec minor?

brachial plexus -- be able to draw this

spinal nerves

cervical nerves are above their respective vertebra (C8 is above T1) thoracic/lumbar/sacral: nerves below vertebra of same #

caliper rib motion

changes A, P and transverse diameters -ribs 11 & 12 -no anterior connection to sternum -movement like calipers opening & closing very painful when stuck, difficult to treat

insertion of pec minor

coracoid process

rib articulations

costovertebral & costotransverse articulations costochondral & sternochondral joints

diagnosing ribs 3-5

count down from rib 3 women: have them pull boob up, put hand on posterior side, put other hand on anterior side seated: feel them posteriorly by using land marks - looking for a smooth opening and closing upon respiration

principle muscles of respiration

diaphragm external intercostals interchondral portion of intercostals

Soft tissue techniques are _ techniques that act to _

direct reduce spasm, ↑ circulation, ↓ hypertonicity, induce general relaxation, ID areas of restriction

myofasical release is a _ technique (tho more of a principal than technique) based on the fascial property of _

direct or indirect creep ((progressive deformation of bodily structures which occurs when the structures are under a constant load they were not designed to handle)) -- in picture, note ground substance: changes viscosity & electrical properties based on amt of stretch it's under

soft tissue circular stretch: combination of perpendicular/longitudinal stretches

erector spinae muscles pictured

soft tissue longitudinal stretch: stretching with the grain of the muscle

erector spinae muscles pictured -

soft tissue perpendicular stretch: taking the muscle & pulling it against the grain

erector spinae muscles pictured - pulling muscles medial to lateral

inhalation rib dysfunction

exhalation restriction stuck *up* key rib: *lowest rib*

What makes rib 1 'atypical'?

flat greatest curvature, shortest length no angle or costal groove 1 facet at rib head articulates with body of T1

motions that occur in the lumbar spine

flexion, extension, sidebending and rotation

diagnosing ribs 6-12

have pt lie prone and feel ribs while they are inhaling/exhaling

landmark for L4

iliac crest

muscles that cause extension of lumbar spine

iliocostalis (bilaterally) longissimus spinalis multifidus

muscles that cause sidebending of lumbar spine

iliocostalis (unilaterally) longissimus spinalis multifidus quadratus lumborum external/internal obliques psoas major

innominate bone includes what bones?

ilium, ischium, pubis

Where to stand in type II dysfunction treatment

in both flexed & extended dysfunctions, stand on opposite side

MRI of lumbar spine

in this view (T2 weighted image), anything with water in it appears white dessicated disk (degeneration involving loss of water & height) between L5-S1, however no herniation bc there is no distension of post. long. lig.

exhalation rib dysfunction

inhalation restriction stuck *down* key rib: *uppermost rib*

muscles of expiration

internal intercostals rectus/transverse abdominus internal/external obliques serratus posterior transversus thoracis

action of the latissimus

internal rotation, extends, adduction of the humerus

absolute contraindications for soft tissue

lack of somatic dysfunction lack of consent

spinal segment between spinous and transverse processes

lamina

'cough' muscle

latissimus dorsi

Rib 10 is associated with which muscle?

latissimus dorsi

forms posterior segment of spinal canal (where spinal cord resides)

ligamentum flavum - continuous over each lamina

pump handle rib motion

like an old fashioned water pump increases AP diameter with inspiration *mixed pump & bucket handle motion for ribs 1-10; higher ribs have more pump motion

rib dysfunctions cause what?

may cause chest, back, shoulder, neck or arm pain may be primary but always accompanies thoracic dysfunction always treat thoracic spine first, then evaluate ribs

muscles that cause rotation of lumbar spine

multifidus external/internal obliques

Rib techniques for practical

muscle energy (probably not HVLA) / MFR (soft tissue)

What makes rib 11 & 12 'atypical'?

no neck or tubercles only 1 facet articulates with corresponding vertebral body no costosternal, costochondral or costotransverse joint

back muscles - erector spinae layer

note TC fascia inserts all the way up at occiput (connecting it to sacrum) - this is partly why sacral dysfunction can cause headaches

typical lumbar vertebra (L2 side view)

note costal process (insertion of longissimus thoracis)

typical lumbar vertebra (L2)

note mamillary process (origin/insertion of intertransversarii mediales lumborum)

origin, insertion, innervation & action of multifidus

origin/insertion: C2-sacrum (between T & sp processes; skipping 2-4 vertebrae) innervation: posterior rami sp nn action: (bilateral) extends spine (unilateral) flexes spine to same side; rotates spine to opposite side

origin, insertion, innervation & action of intertransversarii laterales lumborum (#5 in pic)

origin/insertion: L1-L5 between T processes of adjacent vertebrae innervation: posterior rami sp nn action: (bilateral) stabilizes/extends cervical/lumbar spines (unilateral) sidebends cervical/lumbar spines to same side

origin, insertion, innervation & action of intertransversarii mediales lumborum (#4 in pic)

origin/insertion: L1-L5 between mamillary processes of adjacent vertebrae innervation: posterior rami sp nn action: (bilateral) stabilizes/extends cervical/lumbar spines (unilateral) sidebends cervical/lumbar spines to same side

origin, insertion, innervation & action of interspinalis lumborum (#2 in pic)

origin/insertion: L1-L5 between sp processes of adjacent vertebrae innervation: posterior rami sp nn action: (bilateral) stabilizes/extends cervical/lumbar spines (unilateral) sidebends cervical/lumbar spines to same side

serratus anterior origin: insertion: action: innervation:

origin: (superior) ribs 1-2 (intermediate) ribs 2-3 (inferior) ribs 4 & 9 insertion: medial margin of costal surface of scapula action: superior external rotation of scapula; draws scapula internally & forward; lowers arm from raised position; elevation of ribs innervation: long thoracic nerve & brachial plexus (C5-C7)

serratus posterior origin: insertion: action: innervation:

origin: (superior) spinous processes C7-T3 & ligamentum nuchae (inferior) spinous processes T11-L2; thoracolumbar fascia insertion: (superior) superior margin of ribs 2-5 (inferior) lateral inferior margins of ribs 8-12 action: (superior) elevation of ribs (poserior) lowers ribs innervation: (superior) branches of ventral primary rami of spinal nerves T1-T4 (posterior) branches of ventral primary rami of spinal nerves T9-T12

subclavius origin: insertion: action: innervation:

origin: 1st rib & costal cartilage insertion: acromial end of clavicle action: draws clavicle downward & forward; elevation of 1st rib innervation: subclavian nerve & upper trunk of brachial plexus (C5)

psoas major

origin: T processes T12-L5 insertion: lesser trochanter of femur inserts as the iliopsoas tendon action: flexion of hip joint; external rotation; bends lumbar spine innervation: ventral primary rami of sp nerves L2-L4

internal obliques

origin: deep layer of TC fascia; anterior 2/3 iliac crest; lateral 2/3 inguinal ligament; iliopsoas fascia insertion: lower margins ribs 9-12; pubic crest; anterior & posterior layers of linea alba action: flexion/ipsilateral sidebending of trunk; rotation of trunk contralaterally innervation: intercostal nerves T7-T12; subcostal, iliohypogastric, ilioinguinal nerves

internal obliques origin: insertion: action: innervation:

origin: deep layer of thoracolumbar fascia; anterior 2/3 of iliac crest; lateral 2/3 of inguinal ligament; iliopsoas fascia insertion: lower margins of ribs 9-12; pubic crest; anterior/posterior layers of linea alba action: flexion/lateral flexion of trunk ipsilaterally; rotates trunk contralaterally innervation: intercostal nerves T7-T12; subcostal nerve; iliohypogastric & ilioinguinal nerves

latissimus dorsi origin: insertion: action: innervation:

origin: inferior angle of scapula; ribs 9-12; spinous processses of T7-T12; thoracolumbar fascia; posterior 1/3 of iliac crest insertion: crest of lesser tuberosity of humerus & intertubercular groove action: extension, adduction, internal rotation of arm; aids in respiration innervation: thoracodorsal nerve & posterior cord of brachial plexus (C6-C8)

transverse abdominus origin: insertion: action: innervation:

origin: inner surface of 7th-12th cartilages of ribs; deep layer of thoracolumbar fascia; anterior 2/3 of iliac crest; lateral 1/3 of inguinal ligament insertion: linea alba; pubic crest; pecten pubis action: rotation/flexion/lateral flexion of trunk innervation: intercostal nerves T7-T12; iliohypogastric nerve; ilioinguinal nerve; subcostal nerve

origin, insertion, innervation & action of spinalis thoracis (#8 in pic)

origin: lateral surfaces of sp processes of T10-L3 insertion: lateral surfaces of sp processes of T2-T8 innervation: posterior rami sp nn action: (bilateral) extends cervical/thoracic spine (unilateral) sidebends cervical/thoracic spine to same side

external obliques origin: insertion: action: innervation:

origin: outer surface of ribs 5-12 insertion: linea alba; pubic crest & tubercle; ASIS; iliac crest action: ipsilateral flexion of trunk; contralateral rotation of trunk; compresses abdomen; stabilizes pelvis innervation: intercostal nerves; subcostal, iliohypogastric, & ilioinguinal nerves

external obliques

origin: outer surface ribs 5-12 insertion: linea alba; pubic crest/tubercle; ASIS; iliac crest action: sidebending trunk; rotation contralaterally; compression of abdomen; stabilizes pelvis innervation:intercostal nerves; subcostal, iliohypogastric, ilioinguinal nerves

Quadratus lumborum

origin: posterior part of iliac crest; iliolumbar ligament insertion: rib 12; T processes L1-L4 action: sidebends trunk; fixes rib 12; aids in expiration innervation: subcostal nerve; ventral primary rami of sp nerves L1-L4, T12

transversus thoracis origin: insertion: action: innervation:

origin: posterior surface of sternum; xiphoid cartilage insertion: inner surface of costal cartilages 2-6 action: depression of ribs; compression of chest for forced expiration innervation: intercostal nerves

rectus abdominus origin: insertion: action: innervation:

origin: pubis & pubic symphysis insertion: xiphoid process; costal cartilages of ribs 5-7 action: compression of abdomen; flexion of trunk; stabilization of pelvis innervation: intercostal nerves T5-T12; subcostal nerve

rectus abdominis

origin: pubis; pubic symphysis insertion: xiphoid process; costal cartilages ribs 5-7 action: compression of abdomen; flexion of trunk; stabilization of pelvis innervation: intercostal nerves T5-T12; subcostal nerve

pectoralis minor origin: insertion: action: innervation:

origin: ribs 3-5 insertion: coracoid process of scapula action: pulls scapula medially/forward/down; aids in respiration innervation: medial & lateral pectoral nerves; brachial plexus (C8, T1)

origin, insertion, innervation & action of iliocostalis lumborum (#3 in pic)

origin: sacrum, iliac crest, TC fascia insertion: ribs 6-12, deep TC fascia, T processes of upper lumbar vertebrae innervation: posterior rami, lateral branches of sp. nn C8-L1 action: (bilateral) extends spine (unilateral) sidebends to same side

origin, insertion, innervation & action of longissimus thoracis (#6 in pic)

origin: sacrum, iliac crest, sp processes of lumbar vertebrae, T processes of lower thoracic vertebrae insertion: ribs 2-12, costal processes of lumbar vertebrae, T processes of thoracic vertebrae innervation: posterior rami, lateral branches of sp nn C1-L5 action: (bilateral) extends spine (unilateral) sidebends to same side

multifidus

origin: sacrum; T processes C2-L5 insertion: sp processes of vertebrae superior to their origins action: extension, ipsilateral flexion, contralateral rotation innervation: dorsal primary rami sp nerves C1-L5

longissimus

origin: sacrum; iliac ccrest; sp processes of lumbar vertebrae; T processes of lower thoracic vertebrae insertion: ribs 2-12; costal processes of lumbar vertebrae; T processes of thoracic vertebrae action: extension/lateral flexion of trunk, neck & head innervation: dorsal primary rami of sp nerves C1-S1

iliocostalis

origin: sacrum; iliac crest; TC fascia; medial part of ribs 6-12; angles of ribs 1-6 insertion: T processes of upper lumbar vertebrae; ribs 6-12; TC fascia; T processes of C4-C6; upper angle of ribs 1-6 action: (bilateral) extension; (unilateral) sidebending innervation: dorsal rami of sp nerves T7-L3

spinalis

origin: sp processes at inferior vertebral levels T10-L3 insertion: sp processes at superior vertebral levels T2-T8 & base of skull action: support, extension & sidebending innervation: dorsal primary rami of thoracic nerve & upper lumbar sp nerves

blurb for HVLA

passive & direct 'thrust' technique Employs rapid, brief therapeutic force that travels short distance within anatomic range of motion of joint. Engages restrictive barrier of articular somatic dysfunction in 1 or more planes of motion to elicit release of restriction. Sometimes audible cavitational pop occurs: release of synovial fluid/gas within joint

blurb for myofascial release

passive, direct or indirect technique Engages tissue fascia Uses thermodynamic/mechanotransduction from Dr's hands to pt's soft tissue/fascia Can cause piezoelectric changes which can soften, elongate, relax and release restricted fascial tissues.

Ribs 3-5 are associated with which muscle?

pec minor

spinal segment between transverse processes and vertebral body

pedicle

Pt position & target muscle for treating exhaled ribs 3-5 with muscle energy

percolator pec minor

Savarise review book

pg. 104-105 'viscero somatics' on youtube - student provides guide to memorize

Where does IVD herniation tend to occur?

posterior lateral aspect of disk -- post. long. lig. runs down center (protecting spinal cord & nerve roots), leaving lateral aspects exposed This coincides with the intervetebral foramen, where the spinal nerve root emerges - hence the pain experienced upon herniation - however knocking out a single root is better than if it herniated straight back, it would affect the spinal canal itself & affect all the nerve roots as they travel down

positioning to treat lumbar type 1 lateral recumbent ME

pt lays with rotational component down have them draw knees toward chest while your cephalad hand monitors dysfxn to see when it engages then have them droop superior leg over the table switch monitoring hand to caudad hand; cephalad hand rotates them away from you using their antecubital fossa have pt try to push their shoulder forward

positioning to treat lumbar type 2 lateral recumbent ME

pt lays with rotational component down have them draw knees toward chest while your cephalad hand monitors dysfxn to see when it engages then have them droop superior leg over the table switch monitoring hand to caudad hand; cephalad hand rotates them away from you using their antecubital fossa have pt try to push their shoulder forward

positioning for lumbar lateral recumbent soft tissue

pt lays with treatment side up ask pt to draw knees up toward chest reach over pt's back & place finger pads on medial aspect of paravertebral musculature overlying lumbar T processes exert gentle force ventrally/laterally to create perpendicular stretch of lumbar paravertebral musculature you can also brace the ASIS with your caudad hand

positioning for lumbar bilateral thumb pressure (soft tissue)

pt prone stand at level of pelvis thumbs on paravertebral musculature on either side of spine exert gentle ventral force to engage soft tissues cephalad & laterally until limit of tissue motion is reached (do not drag thumbs across skin; keep them in same spot entire time)

positioning for lumbar prone traction (soft tissue)

pt prone stand either side at level of pelvis warn pt that you will be palpating the area near the small of the back cephalad hand points toward pt's sacrum, caudad hand points toward pt's head gentle force applied ventrally with both hands to engage soft tissue & create separation/distraction effect in direction that fingers of each hand are pointing

positioning for lumbar prone pressure with counterleverage (soft tissue)

pt prone stand opposite side to be treated warn pt that you will be palpating the area near their hip place cephalad thumb & thenar eminence on paravertebral musculature place caudad hand on ASIS, gently lifting it up cephalad hand exerts gentle force *ventrally & laterally, perpendicular* to lumbar paravertebral musculature

positioning for lumbar prone pressure (soft tissue)

pt prone stand opposite side to treated keep elbows *locked* as you apply a gentle ventral & lateral force to engage both the soft tissue & paravertebral musculature

Diagnosing lumbar

pt seated sit behind them find L4 have them sit with legs apart, bend forward, feel all the vertebrae sit next to them, have them cross their arms (I dream of Jeannie pose) Sidebend them & rotate to each side to determine where restriction is

Ribs 1-2 HVLA supine (p. 367)

pt supine sit behind pt's head have them look away (*sidebend away*) from rib you are treating hand sits on top of rib you are treating other hand supports head have pt breathe in, on exhale thrust down in the oblique vector (seatbelt direction)

Inhalation dysfunction: Rib 1-2 supine respiratory assist/muscle energy (p. 367)

pt supine sit behind their head with thumb on dysfunctional rib Use other hand to flex their head, then sidebend them toward, rotate them away from dysfunction Have them breath deeply 5-7x

rib 6-8 exhalation dysfunction treatment

pt supine sit/stand on affected side have pt raise arm and cross over their trunk with hand on opposite shoulder place hand on back to monitor muscle and pull down/out place other hand on their elbow for resistance have them try to move arm against you 3-5x final stretch reassess for TART

Ribs 3-10 HVLA supine (Kirksville Crunch) p. 368

pt supine with arms crossed (tight bear hug, adj over opp usually best to protect boobs) *stand opposite of restriction* roll pt toward you and find spinous, then transverse process. thenar eminence on rib angle, then HAND IS PLACED FLAT SO YOU DON'T BREAK THE RIB have pt roll back on top of your hand push their elbows into your abdomen (their neck will naturally come up) stablize head with other hand have pt breathe in and out deeply on exhale, thrust down into hand (USING BODY WEIGHT NOT UPPER BODY STRENGTH) reassess

positioning for HVLA 'walk around'/Chicago roll

pt supine with hands clasped behind neck stand behind head & R hand through their arms walk around to L side of pt use caudad hand to palpate lumbar while sidebending pt's trunk until component moves rotate pt left use caudad hand to anchor ASIS on opposite side on deep exhalation, apply thrust that *pulls pt into further left rotation*

Rib 12 is associated with which muscle?

quadratus lumborum

muscles that cause flexion of lumbar spine

rectus abdominis internal obliques psoas major

What is caliper motion in exhalation?

ribs 11-12 exhibit caliper motion exhalation: up, in, together (paradoxical)

What is caliper motion in inhalation?

ribs 11-12 exhibit caliper motion inhalation: down, out, separate (paradoxical)

contraindications of myofascial release

same as soft tissue picture: note that fascia is really like a spider web, fibers laid in different directions, thus they can be stretched in multiple directions

Ribs 1-2 are associated with which muscles?

scalenes

Ribs 6-9 are associated with which muscle?

serratus anterior

What is the unilateral action of the sternocleidmastoid?

sidebend same side, rotate opposite

what makes rib 2 'atypical'?

similar to rib 1, but longer & not as flat 2 demifacets on rib head articulate with body of T1 and T2

Side to stand on for exhalation ME ribs 3-5

stand opposite

Side to stand on for exhalation ME ribs 1-2

stand opposite or same side

Side to stand on for exhalation ME ribs 11-12

stand opposite side

rib 1-3 exhalation dysfunction treatment

stand or sit on side of dysfunction have pt raise arm on affected side with hand on forehead (southern belle in distress) and rotate their head away (so they're not breathing on you) place 1 hand medial to scapula, monitoring ribs 1-2 (start at spinous process, move to transverse, then move to rib angle) and pulling caudad place other hand on to her hand have pt try to push against hand by raising their head, attempt to flex neck repeat 3-5x final stretch

Side to stand on for exhalation ME ribs 9-10

stand same side

rib 3-5 exhalation dysfunction treatment

stand/sit on side of dysfunction have pt raise arm in southern bell stance, except hand is above head monitor 3-5 ribs by finding spine of scapula, go to spinous process, then over to rib angle other hand resists by placing hand on upper arm have her try to lift her arm 3-5x final stretch

accessory muscles of respiration

sternocleidomastoid scalenes -anterior, middle, posterior

other accessory muscles of respiration

subclavius pectoralis minor serratus anterior latissimus dorsi

What does 'FUEL' refer to?

the direction of the *force* -- flexed dysfunctions, force toward upper lesion extension dysfunctions, force toward lower lesion

What is the 'key lesion'?

the one you want to treat

A typical rib has a 3rd facet at the tubercle that articulates with what?

transverse process of vertebra at same level -forms costotransverse articulation

Treatment of inhalation rib dysfunction

treat most caudad rib (key rib) use respiratory effort & muscles of exhalation to assist with treatment

Treatment of exhalation rib dysfunction

treat most cephalad rib (key rib) use respiratory effort & accessory muscles of inhalation to assist with treatment

true vs false ribs (which ones are they & where do they attach?)

true: 1-7, attach directly to sternum false: 8-10, attach via cartilage to each other, then to cartilage of rib 7 floating: 11-12

positioning to treat lumbar type 1 seated ME

type 1: Grouped, neutral, SB/R to opposite sides stand opposite side of rotational component pt in "I Dream of Jeannie" pose loop your arm under their first arm (type 1=1 arm) only

positioning to treat lumbar type 2 seated ME

type 2: single, extended/flexed; SB/R to same side stand opposite rotational component pt in "I Dream of Jeannie pose" loop your arm under both their arms (type 2= 2 arms)

What makes rib 10 'atypical'?

typical except 1 facet on the rib head articulates with body of T10

skeletal/ligamentous potential causes for lower back pain

vertebral body anterior/posterior longitudinal ligaments annulus zygapophaseal joint supraspinous ligament

A typical rib has 2 facets that articulate with what?

vertebral body above & at that level

rib exam involves what?

visual inspection palpation (static & with respiration) examine sternal border, rib angle, paraspinal muscles TART