OMM Week 4
PC2 occiput location and treatment
Inferior nuchal line at the attachment of semispinalis capitis ESARA
Bilateral Fulcrum
Longitudonal stretch
Flexion desired Oculocephalogyric (Oculocervical) Reflex
Look down to toes
Cradling with traction
The physician's fingers are placed under the patient's neck bilaterally, with the fingertips lateral to the cervical spinous processes and the finger pads touching the paravertebral musculature overlying the articular pillars.
Cervical Disc Pathology
a. Less common in cervical spine b. May cause symptoms that mimic facet disorders (not gliding in the proper directions) c. May result in neuro signs if compression of nerve root occurs •Pain +/- stiffness •Exacerbated by movement •Exacerbated by increasing disc pressure (cervical compression) •+/- referred pain •+/- Provocative maneuvers for radiculopathy
Describe the process of counterstrain treatment
1.Find the tender point. 2.Assign a pain scale •10 scale •100% •$1 worth of pain 3.Place the patient in the treatment position •Goal to reduce TTP to 0 (100% reduction) •Technique may work with at least 70% reduction 4.Hold treatment position for 90 seconds. 5.Passive return to neutral •Slowly, through a path of least resistance 6.Recheck the tender point and reassess the original somatic dysfunction findings
An 23-year-old male presents with neck pain since a collision during a lacrosse game 4 days ago. Palpatory exam reveals a tender point on the clavicle near the lateral insertion of the right sternocleidomastoid. Which of the following best describes the most likely counterstrain treatment position for the head and neck for this dysfunction? A.Pure extension B.Pure flexion C.Flexion with rotation and sidebending right D.Flexion with rotation and sidebending left E.Flexion with rotation left and sidebending right F.Flexion with rotation right and sidebending leftE. Flexion with rotation left and sidebending right
The location of the tenderpoint indicates that it is AC7 on the right. The classic treatment position for AC3 is flexion, sidebending towards, and rotation away or F ST RA. In this case that is F SR RL
AC 7 location and treatment
clavicle near the lateral insertion of the right sternocleidomastoid F STRA
Cervical Myelopathy
compression of the spinal cord in the neck. PE: Lhermittes sign
Whiplash injury
•Whiplash injuries are cervical injury with a somewhat specific MOI •Acceleration/deceleration injury (extension/flexion, side-to-side) •Typically associated with MVAs •Grading •Grade 1 - Complaint of neck pain or stiffness only •Grade 2 - Complaint of neck pain or stiffness with associated musculoskeletal signs (eg, decreased range of motion, point tenderness) •Grade 3 - Complaint of neck pain or stiffness with associated neurologic signs (eg, decreased or absent deep tendon reflexes, weakness, sensory deficits) •Grade 4 - Complaint of neck pain or stiffness with associated fracture or dislocation •These are typically just diagnosed as a fracture •Grade 1-3 - diagnostic imaging would be negative for osseous injury •OMT - to promote tissue healing, help with inflammation and secondary muscle spasm
An 55-year-old female presents with neck pain since a motor vehicle accident 3 days ago. Palpatory exam reveals Tenderness on the left inferior lateral aspect of spinous process of C2. Radiographs show minimal soft tissue swelling and no fracture. Which of the following best describes the most likely counterstrain treatment position for this dysfunction?
ESRRR The tenderpoint on the inferolateral aspect of the spinous process of C2 is PC3 and is classically treated with flexion, sidebending away, and rotation away or F SA RA. For a point on the left side the position will be F SR RR. Note that PC3 is one of only two posterior cervical tenderpoints for which the classic treatment position involves flexion rather than extension. The other is C1 inion.
Direct OMM diagnoses and examples
Engaging a direct barrier can be somewhat uncomfortable, but techniques often decrease nociception and are generally well tolerated •Muscle Energy •Proposed mechanism - after isometric contraction, neuromuscular apparatus is in a refractory state, during which passive stretching may be performed without encountering strong myotactic reflex opposition •D-MFR •Proposed mechanism - provides neuroreflexive alterations in muscle tone and neural facilitation, in part by its influence on mechanoreceptors •'Hurts so good'
Fryette's 3rd Law
Fryette's third principle states that motion in one plane will modify or reduce motion in the other two planes. Therefore, dysfunction in one plane will reduce motion in the other planes. Consequently, improving motion or reducing the restriction in one plane is likely to improve motion in the other planes.
Cervical Facet Arthropathy
Generalized posterior neck and suboccipital pain Pain may increase with extension and rotation Pain may be referred
PC1 occiput location and treatment
Inferior nuchal line and splenius capitis; midway between inion and mastoid ESARA
PC1 inion location and treatment
Inferior nuchal line, lateral to inion FSTRA
Left rotation desired Oculocephalogyric (Oculocervical) Reflex
Look to left ear
Right rotation desired Oculocephalogyric (Oculocervical) Reflex
Look to right ear
Extension desired Oculocephalogyric (Oculocervical) Reflex
Look to the top of head
LEft sidebending desired Oculocephalogyric (Oculocervical) Reflex
Look up and to the left
Right sidebending desired Oculocephalogyric (Oculocervical) Reflex
Look up and to the right
Orthopedic Exam features
Looking for surgical pathology Central cord or nerve root impingement •Fractures •Spinal instability More objective •'+' or '-' •Ex: Spurling's •ROM: xo - yo •Rotation - 90o L/R
AC1 mandible location and treatment location
Mandible-Posterior aspect of the ascending ramus of the mandible at the level of the earlobe.. f Sa RA (marked rotation away)
AC2-6 location and treatment
On the anterolateral aspect of the corresponding anterior tubercle of the transverse process F SA RA
PC4-8 location and treatment
On the inferior tip or infero-lateral aspect of the tip of the spinous process above ESARA
PC2 Spinous process location and treatment
On the superior tip or superior lateral aspect of the C2 spinous process E
Which of the following most accurately describes the major biomechanical motion of the AA joint? Which of the following most accurately describes the accessory/minor biomechanical motion of the AA joint?
Rotation ------ Sidebend/rotation to opposite sides
Which muscles are associate with the C2 occiput posterior cervical tenderpoint?
Semispinalis capitus
Which of the following most accurately describes the biomechanical motion of the OA joint? A.Flexion and extension only B.Sidebending and rotation to opposite sides C.Sidebending and rotation to same side Which of the following most accurately describes the major biomechanical motion of the OA joint? A.Flexion and extension B.Sidebending and rotation to opposite sides C.Sidebending and rotation to same side Which of the following most accurately describes the accessory/minor biomechanical motion of the OA joint? A.Flexion and extension B.Sidebending and rotation to opposite sides C.Sidebending and rotation to same side
Sidebending and rotation to opposite sides -------- Flexion/extension ------- Sidebdning and rotation to opposite sides
Which of the following most accurately describes the biomechanical motion of the C2 on C3?
Sidebending and rotation to same side with predominance of rotation Cervical motion from C2 on C3 down to C7 on T1 includes flexion, extension, sidebending and rotation. Sidebending and rotation are always coupled to the same side for segmental motion in this region.
Sprain vs strain
Sprain: overstretching/damaging ligaments STrain: T for TENDON, overstretching/damaging tendon. •Sprain - stressing ligaments without adding muscle tension exacerbates symptoms (PROM) •Strain - muscle activation exacerbates symptoms (AROM, stress with resisted muscle contraction)
(Manual) Neck distraction test
Tests for: Cervical radiculopathy Description: Physician applies distraction/traction to patient's cervical spine Positive: relief or reduction of cervical radiculopathy symptoms
Spurling Test
Tests for: Cervical radiculopathy Description: Physician induces lateral flexion (rotation + sidebending) of the patient's neck and applies compression Positive: reproduction of cervical radiculopathy symptoms
Shoulder Abduction (Relief) Test
Tests for: Cervical radiculopathy Description: Physician passively places the patient's shoulder into abduction with hand resting on patient's head Positive: Relief or reduction of ipsilateral cervical radiculopathy symptoms
L'Hermittes Sign
Tests for: Cervical spinal cord compression (myelopathy or other pathology) Description: Passive cervical flexion Positive: Passive cervical flexion elicits electric shock sensation radiating down the spine or extremities
Adsons Test
Tests for: Subclavian Artery Compression (thoracic outlet syndrome) Description: Physician palpates radial pulse while passively abducting the patient's shoulder. Simultaneously patient rotates to ipsilateral side, elevates chin, and holds breath in full inspiration Positive: Loss or reduction of the radial pulse
Roos Test
Tests for: neurovascular compromise (thoracic outlet syndrome) Description: Patient abducts shoulders and flexes elbows. Patient is then instructed to open and close his/her hands for 3 minutes Positive: Reproduction of symptoms (numbness/tingling/pain)
Myelopathy disease and symptoms
Disease of SC SXS: Stiffness, incoordination, weakness and numbness
Radiculopathy disease and symptoms
Disease of Spinal Nerve Root SXS: Weakness and numbness Think MRN
Neuropathy disease and symptoms
Disease: Peripheral nerve SXS: Weakness and numbeness
An 55-year-old male presents with neck upper back pain that began after a prolonged plane flight. Physical exam is unremarkable except for a tenderness on the clavicle near the insertion of the medial head of the left sternocleidomastoid. Which of the following is most likely to describe the proper positioning of the patient's head and neck for treatment of this tenderpoint with counterstrain technique? A.Pure extension B.Pure flexion C.Rotation left D.Rotation right E.Flexion with rotation and sidebending right F.Flexion with rotation and sidebending left G.Flexion with rotation left and sidebending right H.Flexion with rotation right and sidebending left
E. Flexion with rotation right and sidebending right The location of the tenderpoint indicates that it is AC8 on the left. The classic treatment position for AC8 is flexion, sidebending away, and rotation away or F SA RA. In this case that is F SR RR
AC1 transverse process location and treatment
Transverse process-Lateral aspect of the transverse process of C1 RA (90 degrees)
Grade 4 whiplash
•-Complaint of neck pain or stiffness with associated fracture or dislocation
Alternative contact pt for OA ME
•Cephalad hand on head (controlling occiput) •Caudad hand: thumb and index finger contacts the left and right posterior arches or transverse processes of C1
What anterior cervical counterstrain point is Associated with rectus capitis anterior and lateralis muscles
AC1 both anterior and TP
Segmental palpation of the cervical spine most appropriately involves contact of which structures when testing sidebending and rotation?
Articular pillars
Which muscles are the AC2-6 tenderpoints associated with?
Associated with the anterior and middle scalenes, longus capitis and longus colli muscles SCC
PC1 inion is associated with what muscle
Associated with the medial border of the semispinalis capitis and rectus capitis posterior minor
PC1 occiput muscles
Associated with the splenius capitis and/or the rectus capitis posterior major/minor and obliquus capitis superior muscles. "Put a cap on the head"
PC3 location and treatment
At the inferior tip or inferolateral aspect of the C2 spinous process F SARA
AC8 location and treatment
At the sternal attachment of the SCM on the medial end of the clavicle F SARA
Indirect OMM Treatment
Bringing tissue to a balance point decreases nocicipetion •Counterstrain - Mechanism: Shortening dysfunctional myofascial tissues reduces nociceptive input to the CNS-> normalizing neurophysiological activity, myofascial tone and length, and local circulation. •Not all points that are tender = tenderpoint •BLT - Mechanism: positioning tissues at a point of BLT, balance is restored, proprioceptive input is normalized, and the structure will return towards a more functional state •I-MFR - Mechanism: provides neuroreflexive alterations in muscle tone and neural facilitation, in part by its influence on mechanoreceptors
Describe the primary and accessory motions of each cervical vertebra (C0 is the occiput). C0-C7
C0 primary motion is flexion/extension, accessory motion is sidebending/rotation to opposite sides C1 primary motion is rotation, accessory motion is sidebending and rotation to opposite sides C2-C7 flexion/extension, rotation, and sidebending are all primary motions. A certain degree of glide occurs in the cervical spine in multiple planes but this is not assessed or addressed with OMT.
Which cervical V are typical and atypical
C1, C2, and C7 are atypical C2 to C6 are typical
Which of the following most accurately describes the biomechanical motion of the C6 on C7? A.Sidebending and rotation to opposite sides with predominance of rotation B.Sidebending and rotation to opposite sides with predominance of sidebending C.Sidebending and rotation to same side with predominance of rotation D.Sidebending and rotation to same side with predominance of sidebending
D. Sidebdning and rotation to the same side w the predominance of SB
Cervical spondylosis
Degeneration of the cervical vertebrae and disks that produce narrowing of the vertebral canal and intervertebral foramina. In vertebral bodies, facet joints Diffuse pain
Can you use OMT for broken bones
no
Referred pain
pain that is felt in a location other than where the pain originates
Integrated Osteopathic Examination of the Neck
•Clinical Skills' Mneumonic - LARTS NV ------- •Location - verify location of pain with patient by asking him/her to point •Appearance - observe for asymmetry, deformity, swelling, erythema, atrophy, etc. •ROM - active and/or passive •Tenderness - palpate, examine area of concern last •Special Tests - L'Hermittes sign, Spurling test, Cervical distraction test, Shoulder abduction/relief test, Adson's test, Roos test •Neurologic Exam - upper extremity strength, sensation, reflexes •Vascular Exam - carotid, radial pulse
Grade 1 Whiplash
•Complaint of neck pain or stiffness only
Grade 2 Whiplash
•Complaint of neck pain or stiffness with associated musculoskeletal signs (eg, decreased range of motion, point tenderness)
Grade 3 Whiplash
•Complaint of neck pain or stiffness with associated neurologic signs (eg, decreased or absent deep tendon reflexes, weakness, sensory deficits)
Osteopathic Exam features
•Looking for somatic dysfunction •More subjective •TART •Tenderness to palpation (subjective) •Asymmetry •Range of Motion (restriction) •Quality of motion •Tissue texture abnormalities
ME for C2-C7 hand posititions
•MCP/proximal phalange of the physician's left hand firmly contacts the left articular process of the superior vertebra of the dysfunctional segment (Ex: C3) •MCP/proximal phalange of the physician's right hand firmly contacts the right articular process of the superior vertebra of the dysfunctional segment (Ex: C3)
ME of OA landmarks
•MCP/proximal phalange of the physician's left hand firmly contacts the left occiput •MCP/proximal phalange of the physician's right hand firmly contacts the right occiput •Patient's head is cradled in the physician's palms and fingers 3-5
AA finger position ME
•MCP/proximal phalange of the physician's left hand firmly contacts the left posterior arch of C1 •MCP/proximal phalange of the physician's right hand firmly contacts the right posterior arch of C1
Somatic dysfunction neck pain hints
•No MOI, or it is limited and more significant tissue damage is unlikely •Ex: 'I can't think of anything I did...' •Ex: 'I woke up one morning and...' •Acute/subacute •Can be chronic/recurrent, but should look for underlying pathology •Previous negative workup which did not consider somatic dysfunction •Ex: 'I saw ortho/neuro/spine surgeon, they said there was nothing they could do...'
cervical radiculopathy
•Pathology affecting a spinal nerve root. Degenerative changes of the spine (eg, cervical foraminal stenosis, cervical herniated disc) are responsible for 70 to 90 percent of cases ------------------------ •Pain + sensory and/or motor abnormalities •Dermatomal distribution of pain or sensory loss •Myotomal distribution of muscle weakness •Decreased reflexes •Provocative maneuvers - Spurlings test •Ameliorating maneuvers - Shoulder abduction relief test, Cervical distraction test •Diagnostic imaging - MRI is supportive but not always necessary
Presentation of Cervical Sprain/Strain
•Presentation •History of trauma/injury •Pain with movement or stress •Pain may limit function/strength •+/- ecchymosis, soft tissue edema •PE - muscle testing •Provocative vs strength •Can be difficult to distinguish muscular vs ligamentous injury •Sprain - stressing ligaments without adding muscle tension exacerbates symptoms (PROM) •Strain - muscle activation exacerbates symptoms (AROM, stress with resisted muscle contraction) OMT - to promote tissue
Upper extremity neurological exam
•Sensation •C5 to T1 as depicted on dermatome charts •Areas for ulnar, median, and radial nerves •DTRs •Biceps C5-C6 •Brachioradialis C5-C6 •Triceps C6-C7 •Strength •Shoulder abduction (C5 - deltoid) •Elbow flexion (C5, C6—biceps and brachioradialis) •Elbow extension (C6, C7, C8—triceps) •Wrist extension (C6, C7, C8, radial nerve—extensor carpi radialis longus and brevis) •Grip (C7, C8, T1) •Finger abduction (C8, T1, ulnar nerve) Opposition of the thumb (C8, T1, median nerve
•Hints that there is more than just somatic dysfunction
•Significant trauma/injury •Ddx should include fracture, sprain/strain, etc. •Chronic •Ddx should include DDD/DJD/OA, overuse injuries, chronic postural strain •Persistent pain despite appropriate treatment which one would expect to address somatic dysfunction •Previous OMT, other forms of physical/manual medicine (chiropractor, massage therapy, PT, yoga, exercise)
MSK types of cervical neck pain
•Trauma •Fracture •Sprain/strain (whiplash) •Discogenic pain (degenerative disc disease) •Facet arthrosis (degenerative joint disease) •Myofascial pain •Radiculopathy (cervical nerve root impingement) •Myelopathy (central cord compression)
Non-MSK cervical spine pain
•Vascular disease (coronary artery disease, carotid artery dissection) •Infection (meningitis, discitis, osteomyelitis) •Metastatic disease •Referred pain (e.g. from heart, lung, diaphragm, liver, gallbladder, etc.) •Rheumatic conditions (polymyalgia rheumatica, fibromyalgia) •Visceral etiologies (esophageal pathology, thyroid pathology, etc.)
