OMM OMM Board Bo ard Rev Rev iew HISTORY AT Still born 1874 1892 1896 1910 1917 1918
Osteopathy founded "...I flung to the breeze the banner of Osteopathy." 1st class at American School of Osteopathy Vermont first state to license D.O.'s Flexner report AT Still dies Spanish influenza pandemic; osteopathy dramatically reduces morbidity/mortality 1962 D.O.'s exchange degrees for M.D. in California 1973 Mississippi last state to license D.O.'s 2001 Louisiana accepts COMLEX
OSTEOPATHIC PRINCIPLES 1. 2. 3. 4.
The body is a unit. It has its own self-protecting and regulating mechanisms. Structure and function are reciprocally related. Treatment considers the preceding three principles.
AUTONOMICS A UTONOMICS Sympathetic Sympathetic vs. Parasympathetic Parasympathetic Respons Respons e Organ
Sympathetic Sympathetic
Parasympathetic Parasympathetic
Pupil Ciliary Muscle Lacrimal Gland Mucus Glands Salivary Glands Blood Vessels (skin) Pilomotor Muscles Sweat Glands Common Carotid Artery Mucous Glands (Phx-Larx) Thyroid Gland Heart Bronchial Glands Bronchial Muscles Upper body vasculature Stomach Liver
Dilation --------------Inhibition Inhibition Vasoconstriction Contraction Secretory Vasoconstriction Vasoconstriction Vasoconstrictio n Vasoconstriction Excitation Inhibitory Relaxation Vasoconstriction Inhibition Glycogenolysis
Constriction/accomodation Constriction/ accomodation Contraction Secretory Secretory Secretory --------------------------------Secretory -------Inhibition Secretory Contraction -------Motor and secretion Glycogen Synthesis
Spleen Gallbladder & ducts Pancreas Kidney Adrenal Medulla Medulla Intestinal Tract Rectal Sphincter Vesicle Sphincter Vesicle body Uterine Body Uterine Cervix Male Reproductive Organ Ovary and Testes
Vasoconstriction Relaxation Inhibition Vasoconstriction Adrenaline Adrenaline Secretion Contraction Contraction Contraction Relaxation Constriction Relaxation Ejaculation Vasoconstriction
-------Contraction Secretory --------------Relaxation Relaxation Relaxation Constriction Relaxation Constriction Erection (unknown)
Sympathetics Sympathetics Thoracolumbar o utflo w (T1(T1-L2) L2) Head/Neck T1-4 Thyroid T1-4 Mammary T1-6 Esophagus (lower 2/3rds) T1-6 Trachea/bronchi T1-6 Heart T1-6 (T2 on left is most common area of somatic dysfunction for MI) Lung T1-6 Pleura of lung (visceral) T1-6 Pleura of lung (parietal) T1-11 Abdominal Viscera Viscera T5-L2 Stomach T5-9 (left) Duodenum T5-9 Liver T5-9 Gall bladder T5 (right) Gall bladder (ducts) T6 (right) Pancreas T7 (right) Spleen T7 (left) Small intestine to right colon T10-11 Left colon to rectum to pelvic organs T12-L2 Appendix T10 (if not not presented presented with T10 as an option go with T12) (Appendicitis--Right twelfth rib tip is tender) Ovary-/teste T10-11 Adrenals T10-11 Kidney T10-11 Upper ureter T10-11 Lower ureter T12-L1
Cisterna Chyli Pelvic Viscera Uterus Prostate Bladder Upper extremity Lower extremity
T11 T12-L2 T12-L2 T12-L2 T12-L2 T2-8 T11-L2 Sympathetic Innervation Innervation of th e GI GI tract
Greater Splanchnic Nerve (T5-9)
Stomach, Liver Pancreas, duodenum
(T5-9) (10)
Celiac Ganglion
Lesser Splanchnic Nerve (T10-11)
Small intestine Rt. Colon
(T10-11) Superior Mesenteric (12) Ganglion
Least Splanchnic Nerve (T12) & Lumbar Splanchnic Nerve (L1-L2)
Left Colon Pelvic Organs
(T12-L2) Inferior Mesenteric Ganglion
Parasympathetics--cranial and sacral areas CN III CN VII CN IX/X CN X S2-S4
Pupil (constriction and accomodation) Lacrimal/salivary Lacrimal/sali vary glands (secretomotor) sinuses and eustachian tube Carotid body/sinus (blood pressure regulation & C0 2/02 tension) Vagus nerve (thorax. abdomen &- pelvis) Mnemonic 1973 (X. IX. VII. III) Left colon and pelvis via pelvic splanchnic nerve
Parasympathetic Parasympathetic Innervation Innervation Nucleus/Plexus Edinger-Westphal
Cranial Nerve Oculomotor III
Superior Salivatory Facial VII
Inferior Salivatory
Ganglia Ciliary
End Organs Eye , Accomodation
PterygoPalatine & Submandibular
Submandibular/Sublingual Submandibular /Sublingual gland, Lacrimal/palatine Lacrimal/pal atine glands
Glossopharyngeal IX
Dorsal Motor & Vagus X Nucleus Ambiguous
Otic
Parotid Respiration, heart GI, Liver, Pancreas
Pelvic Splanchnic
Pelvic, GU Tract Descending Colon & Rectum
Buzz words for vagus : Dysfunction of the vagus is reflected to OM, OA, AA, C1 & C2. Vagal viscerosomatic reflex from the lungs may be seen as a dysfunction of the OM. Reason for this is probably due to the ganglion nodosum, which is anterior to C2. All organs from the thyroid and below except (?) mammary glands, (?) ovaries and (?) testes. Innervates GI tract up to the middle transverse (right) colon. ALWAYS LOOK AT THE OCCIPUT, SUBOCCIPITAL, C1 OR C2 AREA FOR PARASYMPATHETIC VISCEROSOMATIC REFLEX BECAUSE OF CLOSE PROXIMITY OF VAGUS (GANGLIA NODOSUM) TO THIS REGION. In inferior wall MI: MI : There are many cholinergic fibers located in the inferior wall of the myocardium. Viscerosomatic Viscerosomati c reflex will be to the suboccipital region. The anterior wall MI viscerosomatic reflex is to T1-T7, predominantly T2. Upper respiratory tract : Sympathetics produce epithelial hyperplasia resulting in an increase in the number of goblet cells in relation to the ciliated cells (increased goblet to ciliated cell ratio). Due to this, there is an increase in mucus production and thickening of the secretions. Parasympathetic stimulation produces the opposite. There is increased ciliated to goblet cell ratio. This helps the sweeping mechanism by the thinning of secretions. PUD: PUD: This disease is related to an excessive vagal type of syndrome. Viscerosomatic reflex due to PUD will also be to the OA/OM region. Be aware of pepsin and acid production secreted by parasympathetic overstimulation. Post–Op ileus: Under sympathetic stimulation the intestines contract. During surgery there is an acute disruption of the intestinal system, which goes into shock. Sympathetic override inhibits peristalsis leading to post-op ileus. Rib raising is an effective treatment to tone down the sympathetic gain to the intestines. Misc. Notes: Notes : ♦ Pelvic splanchnic (S2-S4) vs. Sacroiliac joint (S1-S3) ♦ Pelvic splanchnics (S2-S4) innervate from left colon down to genital cavernous tissue except adrenals. ♦ Note: No parasympathetic innervation to the extremities. ♦ Right vagus (AKA Posterior vagal trunk) gives rise to the celiac branch and the left vagus (AKA Anterior vagal trunk) gives rise to the hepatic branch.
The right vagus innervates the Ascending colon and the 1 st 2/3 of the Transverse colon. The left vagus innervates the liver and part of the duodenum. Therefore the right vagus is longer than the left vagus. ♦ Rt. Vagus innervates the SA node: excess parasympathetic stimulation can cause brady arrhythmias. Sympathetic fibers innervate the SA node: hypersympathetic ♦ Rt. stimulation may lead to supraventricular arrhythmias. excess parasympathetic stimulation ♦ Lt. Vagus innervates the AV node: can cause heart block. ♦ Lt. Sympathetic fibers innervate the AV node: hypersympathetic hypersympatheti c activity may lead to malignant dysrhythmias (ventricular tachycardia and ventricular fibrillation). ♦ Sympathetics to the head and neck come from T1 to T4. Travel up to the Superior Cervical Ganglia at the level of C1 to C3, follows the arterial supply and goes through the Sphenopalatine Ganglion without synapsing continuing on to the eyes, nasal mucosa, etc. ♦ Sphenopalatine ganglion is basically a parasympathetic mechanism mainly from CN VII. Covers throat, sinuses, ears and others. ♦ Greater petrosal nerve carries parasympathetic fibers. ♦ Deep petrosal nerve carries sympathetic fibers. th ♦ Hering-Breuer Reflex: Mediated by the 10 cranial nerve occurs when the air sacs are filled with fluid. The respiratory centers receive confusing information. The vagus sends signals to decrease diaphragmatic excursion since the air sacs are filled. Concurrently, the carotid body perceives the need for more oxygen and sends signals to increase the diaphragmatic rate. The result of these signals is rapid and shallow breathing. ♦
Auto Au to nomi no mi cs Big Bi g Pi ctur ct ur e Sympathetics Head/Neck/Heart/Lungs: Head/Neck/Heart /Lungs: Upper GI: Lower GI/Pelvis:
T1-4 (6) T5-9 T10-L2
Parasympathetics Head/Neck: Head/Neck: Chest/Upper Chest/Upper GI: X, Lower GI/Pelvis
CN111, VII, IX, X S2-4
NEUROLOGIC (PROPRIOCEPTIVE) REFLEXES Muscle Energy: (Golgi tendon organ reflex). (Direct method). A pull on the tendon sends signal from the Golgi tendon organ to spinal cord. At the spinal cord inhibitory interneurons synapse with alpha motor neurons causing a reflex relaxation of the muscle. When tension on a tendon becomes extreme the inhibitory effect from the organ can become so great it causes a sudden relaxation of the entire muscle. Golgi tendon organs respond to rate and changes in muscle tension. Summary: Activation of large myelinated group 1b afferent fibers from tendon insertion reflexively inhibits alpha motor neuron to muscle spindle. Buzz: Golgi, alpha motor neurons, tension/force, direct technique. Counterstrain : Decrease gamma gain: "...stop inappropriate proprioceptor activity... shortening the muscle that contains the malfunctioning muscle spindle by applying a mild strain to its antagonist." (Jones) This is an indirect technique that employs the Muscle spindle reflex. This reflex responds to rate and changes of intrafusal fiber length. Hypershortening the extrafusal fibers by bringing the origin and insertion of the muscle mass closer together, decreases the length of the intrafusal fibers and relaxes them. This relaxation phase is followed by a slow return to neutral in order to allow the CNS to reset the gamma gain activity in the spindle to a new lower level. The end result of counterstrain on the muscle spindle fibers is a turning down of the gamma gain. Remember: Position of ease, slow return after 90 seconds. Red herrings: C3 posterior put into flexion. C4 anterior put into extension , inion inion put into flexion, lower pole L5 put into flexion. Key words: proprioceptor, gamma gain. Note: gain. Note: FPR also employs the muscle spindle reflex. HVLA: HVLA : Can involve both the Golgi tendon organ and muscle spindle reflex. HVLA may produce changes in muscle tension and length of muscle spindles. 1. Thrust activation initiates so much afferent input into the CNS, causing the CNS to turn down the gamma gain to the muscle spindles, which relaxes the tight muscle mass. 2. During a thrust the tension on the tight muscle firmly pulls on the tendon. This activates the Golgi tendon receptors, which in turn causes a reflex relaxation to that tight muscle. 3. The stretch of the extrafusal fibers of the tight muscle pulls on the Golgi tendon receptors, which will cause a reflex activation to inhibit the contraction of the same muscle. 4. HVLA of 1/8” to 1/4” of forceful stretching of a contracted muscle may produce such a barrage of afferent impulses from the spindles to the CNS causing the CNS to respond by sending inhibitory impulses to the gamma gain cell bodies. This turns down the gamma gain activity to the spindles, thus relaxing the muscle mass via a central inhibitory reflex.
CHAPMAN'S REFLEXES Chapman’s reflexes are a system of reflex points originally used by Frank Chapman, D.O. These reflexes present as predictable anterior and posterior fascial tissue texture abnormalities assumed to be reflections of visceral dysfunction or pathology (viscerosomatic reflexes). A given reflex is associated with the same viscus; Chapman’s reflexes are manifested by palpatory findings of plaque-like changes of stringiness of the involved tissues. The Chapman's reflexes follow sympathetic afferent pathways and therefore are manifest along the dermatome, sclerotome and myotome segmental lines. Chapman’s reflexes are neurologic, lymphatic and myofascial reflexes that indicate increased functional activity of the sympathetic nervous system. They do not reflect the parasympathetic nervous system. These reflexes in the thoracic area are palpated anteriorly in the intercostal spaces via sympathetic fibers of intercostal nerves. The heart reflex is located at the 2 nd intercostal space and posteriorly at T2, which is a major innervation of the heart. The reflex for the bronchus, thyroid and esophagus is also at the anterior 2 nd intercostal space. The Chapman’s reflexes for the colon are located on the lateral thigh along the Iliotibial band and Tensor fascia lata. Also, in this same area are the reflexes for the broad ligament of the uterus and prostate. The reflex for the cecum is located at the Rt. Greater Trochanter and for the sigmoid colon at the Lt. Greater Trochanter. Ex. Disorder in middle ear and sinuses will increase sympathetic tone to clavicle and first rib anteriorly and C2 posteriorly. They tend to follow classic viscerosomatic patterns.
OTHER TREATMENT MODALITIES MODAL ITIES • • •
Effleurage: Form of lymphatic stroking, distal to proximal Petrissage: Grasp, lift and twist skin to break superficial fascial adhesions. Tapotement: Striking belly of muscle with hypothenar eminence to increase blood flow and tone
SOMATIC DYSFUNCTION Somatic Somatic dysfunction : Is an 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 . Mnemonic: SAM VLN. Remember TART ( TART (T Tissue texture changes, Asymmetry, A symmetry, Restricted motion & Tenderness) Ac ut e:
• • •
•
Increase temperature (blood flow from kinins, etc). Increase moisture (sudomotor from sympathetics). Increased bogginess (edema from leakage of vessels and stagnant lymph) Increased tenderness (nociceptor firing in tissues). Erythema (vascular response, redness lasts more than 15-30 seconds).
Chronic: Decreased temperature (cool, decreased blood supply from ongoing • sympathetonia). • Dryness (sustained sympathetic tone "burns out" sweat glands and decreases sudomotors). Blanching in response to erythema streaking (sympathetics vasoconstrict • blood vessels). • Ropy, stringy, soft tissues.
ERYTHEMA TEST Acut Ac ute: e: A A positive red reflex sign due to release of substance P and other biochemical neuropeptides, kinins, etc., into soft tissues causing dilation of capillaries and inflammation. Redness shouldn't last > 30 sec. Chronic: There is a blanching response due to excess vasoconstriction from sympathetic override.
BARRIERS Restrictive Barrier: A functional limit within the anatomic range of motion, which abnormally diminishes the normal physiologic range (1). (Between normal midline range and physiologic barrier). AKA: Pathologic Barrier. Physiologic Barrier: The limit of active motion; can be altered to increase range of active motion by warm-up activity . Anato An atomi mi c Barri Bar ri er : The limit of motion imposed by anatomic structure; the limit of passive motion. (End point of ligament, fascia, muscle, etc. Beyond these joint is disrupted). Pathologic Barrier: 1. Restrictive barrier; 2. Permanent restriction of joint motion associated with pathological change of tissues (ex. Contracture, osteophytes). Elastic Barrier: The range between the physiologic and anatomic barrier of motion in which passive ligamentous stretching occurs before tissue disruption.
FRYETTE'S LAWS Type I: Sidebending and rotation to opposite sides. • Involves more than one segment (usually 3 or more) = group curve. • Dysfunction greatest in neutral (N) position. • • Long restrictors maintain lesion (erector spinae). • Compensatory/gradual Compensatory/g radual onset. Treat after Type II. • Example: T3-L1 N SBI Rr: To treat put patient into RI SBr N (for muscle energy). • Type II: • • • • • • •
Sidebending and rotation to same side. Single segment. Dysfunction greatest in either flexion or extension. Short restrictors maintain lesion (rotatores brevis & intertransversarii muscles.) Abrupt/traumatic Abrupt/traumat ic (found at apex, beginning or end of group curve). Treat first. Example: T8 F SBl Rl: To treat put patient into Rr SBr E (for muscle energy).
Law III: • Named by Dr. CR Nelson in 1948: Initiation of motion in one plane MODIFIES motion in all other planes.
RULE OF THREES FOR THORACIC SPINE A. T1-3 B. T4-6 below C. T7-9 D. T10 E. T11 F. T12
Spinous process process of segment is with its transverse process Spinous process of segment is half way, to t-process of segment Spinous process of seg. is at level with t-process of seg. below Like "C" Like "B" Like "A"
FACILITATION 1. The maintenance of a pool of neurons (e.g. premotor, motorneurons or preganglionic sympathetic neurons in one or more segments of the spinal cord) in a state of partial or subthreshold excitation; in this state, less stimulation is required to trigger the discharge of impulses. 2. Facilitation may be due to sustained increase in afferent input, or changes within the affected neurons themselves of their chemical environment. Once established facilitation can be sustained by normal CNS activity.
3. Synapses in the cord that have low threshold are easily triggered by impulses of sublevel intensity. Visceral afferent and somatic propioceptor bombardment to the cord from visceral or somatic disease produces facilitation. These facilitated segments will then fire sympathetic outburst to related organ and soma structures when other visceral or somatic impulses pass through that region of the cord. This inappropriate sympathetic bombardment of visceral and somatic tissue will have detrimental effects to these tissues and the body in general.
DERMATOMES C5 C6 C7 C8 C5-C6 C5-C7 C8-T1 T4 T7 T10 T12 L4 L5 S1 L4-L5 L3-L4 L5, S1-S2 L1-L4 S1-S5
Clavicles Thumb Middle finger Ring/Little Finger Ball of shoulder (deltoid) Lateral Arm (C5 for lateral upper arm, C6 for lateral forearm) Medial Inner Arm Nipple Xyphoid Umbilicus Groin Innermost foot Dorsum of foot Outermost foot Medial Foot Knee Posterior/Outer Posterior/Ou ter Thigh Anterior/Inner Anterior/Inn er Thigh Perineum
T1 – In MI, T1 is probably the connection to viscerosensory pain referral to the inner arm. Viscerosensory vs. viscerosomatic = pain vs. tissue texture changes Pain: In general, pain above the uterine fundus is mediated by the sympathetics. Pain below (except the gonads) are mediated by the parasympathetics.
Perineum (S1-S5), very important when assessing for Cauda Equina Syndrome. Patient with large central disc herniation will have trouble with urinary or bowel retention.
KEY REFLEXES REFL EXES L4 L5 S1 C5 C6 C7
Patella (knee jerk) None (test strength of great toe dorsiflexion-extensor dorsiflexion-extenso r hallucis longus-- and heel walking) Achilles (ankle jerk/toe walking) Biceps Brachioradialis Triceps
CRANIAL Founded in 1899 by Dr. A.T. Still's student. William Gardner Sutherland. D.O. Five phenomena: phenomena : 1. The fluctuation of the cerebrospinal fluid (or potency of the Tide) 2. The motility of the brain and spinal cord (alternating shape of CNS) 3. The mobility of the intracranial and intraspinal membranes (reciprocal tension membranes) 4. The articular mobility of the -- cranial bones joint/suture motion) 5. The involuntary movement of the sacrum between the ilium (via the dural membranes to S2) #’s 1 and 2 and 2 are thought to be the "motive power" behind #’s 3-5 The five phenomena make up the Primary Respiratory Mechanism. Note: Note: Most cranial dysfunctions are named in relation to the position of the sphenoid bone. Flexion: Increase in transverse diameter, decrease in longitudinal and A-P diameters. Extension: Decrease in transverse diameter, increase in longitudinal and A-P diameters. Torsion: Twisting of articulation of sphenoid and occiput, the sphenobasilar synchondrosis. Name lesion for side of higher greater wing of the sphenoid. Greater wing of the sphenoid is superior on the right and a low occiput on the right = Rt. Torsion. Torsion . Sidebending/Rotation: Bending of articulation of sphenoid and occiput, the SBS; the low greater wing of sphenoid is on same side as low occiput, head fuller, convex, on this side and named for this convex side (of low sphenoid and low occiput). Mnemonic: "Down and Out in Beverly- Hills". Greater wing and
occiput both inferior on the right and convex (fuller) on the right Sidebending/Rotation
= Rt.
Lateral Strain: Sphenoid shifted to either right or left of occiput. Sphenoid shifted to the right in relation to the occiput = Rt. Lateral Strain . Traditionally named for which side the basisphenoid shifts towards, however, recently contested by some to be defined as to the direction opposite the sphenoid is shifted towards. towards . It’s really an intellectual argument because they are both incorrect according to Magoun's Osteopathy in the Cranial Field. He contends that the greater wing of the sphenoid actually shifts ANTERIORLY in a right lateral strain and ANTERIORLY in a left lateral strain. Parallelogram head. Vertical Strain: Sphenoid shifted up or down in relation to the occiput. If sphenoid is shifted upward, for example from a punch to the bottom of the chin upward, then it’s a superior vertical strain. If shifted downward, it's an inferior vertical shear. When palpating in an A/P direction along the frontal bone and there is a dip at the coronal suture = anterior cranium is superior = Superior vertical strain. If anterior cranium (dividing line being the coronal suture) is inferior = Inferior vertical strain. A hit with a bat on head anterior to the coronal suture or a fall on the tailbone may result in an Inferior vertical strain. The later is possible since there is a change in the relation of the sphenoid and the occiput. Caution: do not no t name the lesion in relation to the occiput. Compression: A-P compression at sphenobasilar symphysis, worst lesion: overall decreased cranial motion. Described as a "bowling ball " head. Bones: 22 cranial 22 cranial bones. • • 28 if 28 if you count the ossicles (3 in each temporal bone). • 8 neurocranial bones (occiput, temporal (2), ethmoid, parietals (2), sphenoid and frontal). 14 viscerocranial 14 viscerocranial bones (facial). • 7 orbital bones (frontal, zygoma. maxilla, sphenoid, lacrimal, ethmoid and • palatine). 29 bones 29 bones in the cranium (incl. Hyoid and Ossicles) • 79 articulations 79 articulations in the face • • 43 articulations in the cranium 55 articulation 55 articulation in the foot • • 26 bones 26 bones in the foot • The skull has about 142 articulations. (79 face, 43 neurocranium) Basilar bones are occiput (except interparietal portion), petrous temporals, • sphenoid (except tip of greater wing) and ethmoid and are all formed in cartilage.
•
Vault Vault bones are frontal, parietals, and temporals (include tip of greater wing of sphenoid and interparietal occiput). All formed in membrane and are accommodative to the basilar bones.
Sphenobasilar synchondrosis: Major joint in cranium, formed in cartilaginous tissue, becomes cancellous bone around the age of 25 and maintains pliability, flexibility thereafter. Movement: Normal cranial rate is 8-14 cycles/minute. A cycles/minute. A cycle = 1 inhalation & 1 exhalation. Cranial amplitude is quantitative 1/10 – 10/10. The latter being healthiest Inhalation phase of phase of the primary respiratory mechanism (PRM) = flexion of midline structures, (i.e. sphenoid, occiput, sacrum) and external rotation of paired structures (i.e. temporal bones, femur, etc.). Exhalation phase of phase of PRM = extension of midline structures and internal rotation of paired structures. Occiput, ethmoid and vomer all rotate (circumducts) in the same direction in flexion and extension. Sphenoid rotates (circumducts) in opposite direction.
Landmarks:
•
• • • • • • •
•
Pterion: Overlapping of frontal parietal sphenoid and temporal. Area of anterior branch of middle meningeal artery. Asterion: Meeting of parietal, temporal and occiput. Opisthion: Dorsal aspect of foramen magnum. Basion: Ventral aspect of foramen magnum. Nasion: Meeting of frontal and nasal bones. Glabella: Bump on distal frontal bone, above nasion. Bregma: Meeting of coronal and sagittal sutures. SS pivot point: Sphenosquamous point where temporal overlaps the sphenoid superior to joint and sphenoid overlaps temporal below point. Sutherland's Fulcrum: Area of straight sinus (junction of three sickles of dura mater); automatic shifting suspension fulcrum “… point of rest on which a lever moves and from which it gets its power..." (Magoun)
Beveling:
External bevel : Suture is on the external surface of the bone. If a bone is externally beveled it is overlapped by another bone. Internal bevel : Suture is on the internal surface of the bone. If a bone is internally beveled then it overlaps another bone. Example: At the occipitomastoid suture the Temporal has internal beveling and the Occiput has external beveling. In this case the Temporal overlaps the Occiput. Note: Above the SS pivot point the temporal overlaps the sphenoid and below this point the sphenoid overlaps the temporal.
The beveling concept gives an indication of how certain treatment would work. When treating a patient with a CV4 the occiput is compressed since it is overridden by the temporals. The Three Three Articul ations b etween etween th e Temporal Temporal and Occipital Bon es: 1. Condylosquamomastoid Condylosquamomast oid Pivot: Rocking motion 2. Jugular Process: occiput drives the temporal 3. Petrobasilar: Tongue and groove & Hinge/Glide motion 4. Combination of all three equals “wobble” The Major Attachments of the Dura (Reciprocal Tension Membrane): 1. Posterior pole: Occipital bone 2. Lateral poles: Petrous portion of the Temporal bone 3. Anterior Superior pole: Cribiform and Crista Galli of the Ethmoid 4. Anterior Inferior pole: Clinoid processes of the Sphenoid 5. Inferior pole: S2 at the superior transverse axis of the sacrum Flow of CSF: CSF:
Lateral ventricles Interventricular foramen of Monroe 3 rd ventricle Aqueduct of Sylvius 4th ventricle through Midline foramen of Magendie or lateral to foramen of Luschka subarachnoid space brain and spinal cord
Venous flow: ♦ Superior Sagittal sinus Rt. Transverse sinus ♦ Inferior Sagittal sinus Lt. Transverse sinus ♦ Transverse sinus Sigmoid sinus Internal Jugular Vein which courses along with CN IX, X & XI and exit through Jugular Foramen which is between two bones, the occiput and temporal. ♦ Great vein of Galen together with the Inferior Sagittal sinus Straight sinus Confluence of Sinus ♦ Cavernous sinus empties into the Inferior and Superior Petrosal sinuses. Inferior Petrosal sinus Sigmoid sinus and the Superior Petrosal sinus Transverse sinus. ♦ The venous sinuses lie between the two layers of dura. These veins lack smooth muscle, elastic fibers and valves. They are dependant on the mobility of the dura for drainage. Techniques : CV4 CV4 (compr (compr ession of t he fourth ventri cle): Generalized technique, used in any instance except acute head trauma. Operator places thenar eminences medial to mastoid processes: encourage extension phase by holding the occiput towards you (very gently!) or away from the flexion phase. You are harnessing the "Potency of the Tide." Pronounced effect on total body physiology. For example: The medulla is on the floor of the fourth ventricle; if you work with the CSF to alter this respiratory center you can in turn effect a change in the thoracoabdominal diaphragm and hence increase lymphatic flow from the cisterna chyli/thoracic duct via the aortic hiatus in the diaphragm (level of T12). Sphenopalatine Ganglion : It hangs in its respective fossa via the second division of CN V, but it is supplied by the greater petrosal nerve, a branch of the geniculate ganglion of CN VII. To treat: Go to maxillary ridge near pterygoid plate and gently inhibit to effect a decrease in goblet to ciliary cell ratio and lessen thickened secretions of the nasopharynx (especially the Eustachian tube).
CRANIAL CRANIA L NERVE ENTRAPMENTS ENTRAPMENTS Cranial Nerve Entrapment Neuropathy I Olfactory Anosmia II Optic Visual Acuity/Field Acuity/Fiel d III Oculomotor Eye deviation - down and out Pupils not constricting (via Edinger-Westphal Nucleus) IV Trochear Eye deviation - slight upward V Trigeminal* Anesthesia of the face, paralysis of muscles of mastication, Trigeminal Neuralgia (V2)-Stabbing pain VI Abducens Eye deviation - inward, strabismus VII Facial Bells Palsy, Decreased Tears/Taste to anterior 2/3 of tongue VIII Vestibulocochlear Decrease hearing, vertigo, Meniere's disease IX Glossopharyngeal Decreased swallowing X Vagus Anesthesia of External auditory meatus Circulation/Respiration changes Digestion, swallowing Swallowing/Speaking XI Accessory Shoulder shrugs, swallowing XII Hypoglossal Tongue: Suckling *Trigeminal neuralgia most commonly occurs in V2 distribution. -V1 exits via the Superior Orbital Fissure -V2 exits via Foramen Rotundum -V3 exits via Foramen Ovale
PELVIS AND SACRUM ♦
Standing flexion Test provides information on laterality or iliosacral dysfunction. The seated flexion test provides information only on sacroiliac dysfunction, not on laterality, except to say that the side of the (+) seated flexion test is opposite the axis (named) or the same side as the inferior pole of the axis = piriformis spasm.
♦
Example of Innominate diagnosis: Lt ASIS - Superior Lt PSIS - Inferior Lt Pubic Bone - Superior (+) Rt Standing Flexion Test Dx = Rt Innominate Anterior Rotation
Lt ASIS - Inferior Lt PSIS - Inferior Lt Pubic Bone Inferior (+) Rt Standing Flexion Test Dx = Rt Innominate Superior Shear
Distance from ASIS to umbilicus is greater on the right, with a positive standing flexion test on right=right outflare innominate. Distance from ASIS to umbilicus is less on right than on left, standing flexion test positive on the right=right inflare
innominate. Same as above but positive standing flexion test on the left=left outflare innominate. ♦ The axis in a sacral torsion is named for the superior pole of the axis ♦ The “stork test” is positive for INNOMINATE INNOMINA TE or iliosacral dysfunction: Operator palpates PSIS, pt bends knee (one side) and you see if PSIS comes posteriorly. If it does NOT, then a restriction or dysfunction of the INNOMINATE/iliosacral is noted. ♦ The “Sphinx test” just has the patient prone, in “TV watching position” to induce lumbar extension. It would make a “backward sacral dysfunction” worse. A forward sacral dysfunction would be more symmetrical. ♦ For sacral torsion remember that L5 is rotated opposite to the rotation of the sacral rotation. ♦ Superior transverse axis of the sacrum corresponds to Respiratory motion/ craniosacral. Middle transverse axis for sacroiliac motion and the inferior transverse axis for iliosacral motion. For all of these axes motion occurs through S2. ♦ A question regarding a resistant ILA is referring to a posterior/inferior ILA ♦ Anterior Superior ILA on the Rt = Posterior Inferior ILA on the Lt ♦ Counternutation of the Sacrum = Base is posterior = Craniosacral Flexion = Postural extension ♦ Nutation of the Sacrum = Base is anterior (nods) = Craniosacral Extension = Postural flexion st ♦ In the birthing process, as the baby comes down the birth canal the sacral base 1 moves posteriorly in counternutation and 2 nd as the baby comes further down the apex of the sacrum moves posteriorly in nutation.
Sacral Sacral Dysfuncti ons Torsion: By definition deep sacral sulcus opposite from side of inferior lateral angle (ILA) being posterior-inferior. That is the sacrum moves about an oblique axis. Should have concomitant somatic dysfunction of the lumbar region (with lumbar or lumbars rotated to the opposite side of the sacral rotation). Torsions either forward (left on left. right on right) or backward (right on left, left on right). Most common: Left on left forward sacral torsion. Note: L5 must be rotated in the opposite direction as the sacrum to be a torsion. Also, the seated flexion test is generally positive on the side opposite the axis
because the inferior pole of the axis is fixed by a piriformis spasm. The superior pole of the axis is fixed by a quadratus lumborum spasm. Rotation: L5 is rotated in SAME direction as sacrum. Flexion/Extension lesions: Remember flexion/extension in the muscle energy model is opposite the cranial model. That is the postural and respiratory models are not to be confused. Both have an axis in the S2 region, but then, are called "middle transverse" for the postural, muscle energy model and "superior transverse" for the respiratory cranial model. If a deep sacral sulcus is on the same side of the ILA being posteriorinferior it is a unilateral sacral flexion lesion or sacral shear. For example: Deep sulcus and posterior-inferior ILA on the left = left unilateral sacral flexion lesion or left sacral shear. If both sulci deep = bilateral sacral flexion. If both sulci, shallow = bilateral sacral extension. Most common USFL/shear is on left. Mnemonic: United States Football League. You can also have a bilateral sacral flexion or extension lesion (postural model) whereby the sacral sulci are either deep or shallow bilaterally.
The fifth lumbar: Is key to the latest version of sacral dysfunction: If L5 is rotated opposite to the sacrum you most likely have a sacral torsion. If L5 is rotated in the same direction then it is a sacral rotation. Spring test: Used to distinguish whether you have a backward v. forward sacral torsion. If the lumbars are taut, kyphotic, tense and do not spring well on compression in the prone position = positive spring test. If the lumbars retain natural lordosis and are flexible = negative spring test. Positive = backward torsion. Negative = forward torsion. Nomenclature: Name Rotation on Axis.
Mnemonic: Rheumatoid A heumatoid Arthritis rthritis
Note: Spring test equivocal or negative and positive with shear. Note: Positive sitting flexion test is opposite the axis in a torsion and ipsilateral in a shear. Note: Sacrotuberous ligament taut on side of posterior inferior ILA and posterior innominate. Forward sacral sacral torsi on : In any torsion whether it's forward or backward always lie the patient on the involved axis. If left axis, lie on left side, etc. etc. For forward torsion, lie in the lateral Sims's position, that is their chest is forward on the table. Have patient flex both legs and attempt to bring both ankles toward the ceiling against your isometric resistance. Backward sacral torsion : Patient in lateral recumbent position that is their back is towards the table. Have patient straighten out bottom leg on table, flex upper leg and attempt to bring their ankle towards the ceiling against your isometric resistance. Unilateral sacral flexion or sacral shear : Patient prone. You place thenar or hypothenar eminence on their ILA and push cephalad and anteriorly as they exhale. Resist inhalation. Sacral Rotations: Essential L5 is rotated in the same direction as the sacrum.
Summary: FST: FST: Negative spring, deep sulcus opposite post/inf ILA: lat. Sims's (forward on table 2 legs) BST: BST : Positive spring, deep sulcus opposite post/inf ILA: lat. recumbent (back on table I leg). USF/shear : USF/shear : Equivocal spring, deep sulcus ipsilateral to post/inf ILA; prone position. Primary ligaments of sacrum : Anterior interosseous and posterior sacroiliac ligaments
Acces Ac cesso sory ry li gament gam ents s of o f s acrum acr um : Sacrospinous, sacrotuberous and iliolumbar ligaments. Note: Sacrotuberous ligament is taut with a post/inf ILA or posteriorly rotated innominate. Note: Note: Iliolumbar ligament attaches from the transverse processes of L4/5 to the PSIS/iliac PSIS/il iac crest. Dysfunction here can refer pain to groin and simulate "hernia" symptoms. Sacral motion during vaginal delivery: Counternutation = base going in extension or backward about the middle transverse axis. Nutation (nodding) = base going in flexion or forward about the middle transverse axis. axis.
THE MANY DIAPHRAGMS DIAPHRA GMS OF THE THE BODY Tentorium cerebelli : Dura neater lying transversely on posterior cranial fossa separating cerebellum from cortex. Area of automatic shifting suspension fulcrum (of Sutherland). Sibson's fascia: fascia : Thoracic inlet, measures 4 by 2 inches, attaches C7-TI around first rib to manubrium, also attaches to cupula of lung. Comprised of fascia from the scalenes and the longus colli muscles. Thoracic duct travels up through and down through this diaphragm before entering into the venous circulation (left internal jugular and subclavian or brachiocephalic veins). Thoracoabdominal: Thoracoabdomina l: 60% motive force for inhalation. Innervated by C3-5 somatic nerves. Hiatus for vena cava is T8, esophagus is T10 and aorta (and thoracic duct) is T12. Pelvic: Pelvic : Comprised of two muscles, levator ani and coccygeus. Somatic and parasympathetic innervation by the cord segments S2-4 (pudendal and pelvic splanchnics respectively). Popliteal fossa: Fascial pathways for lymph from the leg. Medial longitudinal arch of foot : Navicular and plantar fascia supportive and stress bearers.
THORACIC INLET VS. THORACIC OUTLET OUTL ET Thoracic Inlet : Structures coming from the head, neck and upper extremity enter the thorax through the thoracic inlet. It is the opening for the pharyngeal structures into the thorax and is one of the diaphragms of the body.
Keep in mind that these diaphragms assist in maintaining the intracavitary pressures (intrathoracic {-}, pharyngeal {+} and abdominal/pelvic abdominal/pelvi c {+}). The maintenance of these pressure gradients is vital for fluid movement. The thoracic duct travels up through the thoracic inlet to the level of C7, then reenters the thoracic cavity through the thoracic inlet to empty into the venous system. Buzz words for the thoracic inlet: Sibson's fascia and suprapleural membrane. These keep the pharyngeal structures from being "sucked" into the thorax by the negative pressure in the thoracic cavity. Thoracic Inlet Structures Apices of the the lungs Trachea Esophagus Brachiocephalic veins Vagus Cervical symphathetics Phrenic Nerve Thoracic Duct
Functional T1, T2, T3, T4 Ribs 1 & 2 Manubrium
Anatomic Manubrium Ribs 1 & T1
Thoracic inlet assessment : This is used to assess the dimension of thoracic inlet torsion. Example: If the left coracoclavicular angle is anterior or more convex = right coracoclavicular angle is deep = Thoracic inlet is rotated to the right. If left rib is elevated = Thoracic inlet is sidebent to the right. Rotation is assessed by the coracoclavicular angle or infraclavicular fossa. Sidebending is determined by an elevated 1 st rib. Thoracic Outlet: Structures leave the thorax through the thoracic outlet mainly to the upper extremities. Thoracic Outlet Clavicle 1st rib Neurovascular Bundle Downward displacement of the clavicle onto the 1 st rib may cause compression of the neurovascular bundle resulting in thoracic outlet syndrome. Compression of the subclavian artery and brachial plexus may occur: (1) As these structures pass through the triangle formed by the 1 st rib and the anterior and medial scalenes; (2) As the
neurovascular bundle passes between the pectoralis minor near its attachment to the coracoid process and the rib cage.
COMMON COMMON COMPENSATORY PATTERN OF ZINK Dr. Zink described patterns of fascia, which alternated direction at certain anatomical junctions junctions (OA, Thoracic Inlet, Inlet, Thoracolumbar Thoracolumbar area, Lumbosacra Lumbosacrall area). These junctions junctions coincide with diaphragms of the body. According to Dr. Zink the alternating fascial patterns are the body’s response to provide postural compensation. Most common pattern is L, R, L, R. • • • •
OA-- Rotated to left. Thoracic inlet-- Rotated (and side-bent) to right Thoracolumbar junction-- Rotated to left Lumbosacral junction-- Rotated to right
Note: This is the most compensatory (physiologic) pattern of fascial directions. As long as it alternates L-R-L-R (80%) or R-L-R-L (20%) this is good. Very dysfunctional to have R-L-L-R or R-R-R-R, etc.
LYMPHATICS Right minor system vs. Left main thoracic drainage. Right upper extremities, Rt. Hemicranium, heart and lungs (except the Left upper lung) drains into the right thoracic duct. The right thoracic duct in turn drains into variable sites one of which is the Rt. Brachiocephalic vein. The left thoracic duct drains into the junction of the Subclavian and Internal Jugular veins. Ex: Lymphangitis of the Lt. Foot will eventually drain in the Lt. Thoracic duct and an abscess of the Rt. Index finger would drain into the Rt. Thoracic duct.
SPINAL CORD/COLUMN Facets of cervical spine are oblique. Facets of thoracic spine are coronal. Facets of lumbar spine are sagittal. Cervical Cervical spine: OA = flexion/extension (50%) AA = rotation rotation (50%) C2-7 = increasing sidebending as you proceed distally Spinal cord: cord : Ends at L1-2 vertebral level (L3 in infant) Thirty-one pairs of nerve roots (8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal)
SCIATIC NERVE • •
•
•
Comprised of L4-L5 and S1-S3 Peroneal portion pierces belly of Piriformis 10% of population. Most often exits inferior to muscle and 0.5% exits superiad to muscle. “Sciatica” is a lay term to describe a syndrome of chemical irritation of the nerve bundle, usually related to piriformis spasm, in which pain does not extend below the knee. Note: “Psoas syndrome” usually involves contralateral piriformis spasm.
MUSCULOSKELETAL MUSCULOSKELETAL PATHOLOGY Herniated Disc Herniated intervertebral disk (herniated nucleus pulposus): A posterior-lateral herniation of the nucleus pulposus through the posterior longitudinal ligament. Most common between L4-5 and L5-S1 vertebral segments. Specifically, however, the fifth lumbar disk (btw L5-S1) is the most commonly herniated. Lower extremity radiculopathies are mainly from L5-S1. Which nerve gets impinged in a disc herniation at L5-S1? L5 or S1? The nerve root that is affected is S1. Herniations affect the nerve root of the lower vertebral level. (See Netter’s plate no. 149). Spondylolisthesis It is also the most ♦ Most common type is isthmic spondylolisthesis (Type IIA). common cause of lower back pain in the pediatric population. ♦ Spondylolisthesis Spondylolist hesis is a primary defect of the pars interarticularis.
♦
♦ ♦
♦
Anterior slippage of one vertebra on its subjacent vertebra. Most commonly L5 slips forward on S1. Most commonly occurs in the general population of < 50 y.o. The affected children will have an exaggerated lumbar lordosis, high gluteal crease line and tight hamstrings. The hamstrings innervation is between L5-S1 nerve roots. The nerve roots are not necessarily impinged but they are affected and cause somatosomatic reflex. A Scotty dog seen on X Ray is a sign for spondylolysis: Collar:
Microfracture between the superior and inferior articular facets Eye: Pedicle Hind leg: Spinous process Fore leg: Inferior articular facet Nose: Transverse process Spondylolysis: Defect Spondylolysis: Defect in the posterior neural arch (pars interarticularis which is at the junction of the superior superior and inferior articular facets): usually bilateral; bilateral; postulated postulated as microfractures sustained over time; gives rise (usually) to....listhesis. Spondylitis: Spondylitis : Inflammatory arthritis of the spine begins at sacroiliac, joint and ascends up spine then extremities, males, 15-30 years old. Spinal stenosis : Result of DJD/disk degeneration; spinal foramen closes due to calcium build up and compromises spinal cord (normal AP diameter of canal is 1.2-1.5 cm). Gives rise to pseudoclaudication" in which radicular symptoms are worse in lumbar extension, for example, standing or walking. Symptoms are better with lumbar flexion, for example sitting. "Pseudo" because true aortic-iliac plaque stenosis would give leg pain/paresthesias that are relieved by simple rest, i.e. standing, which would not relieve cord compromise (spinal stenosis). L5: L5 : Best answer for the vertebra with “the most common congenital malformations”. Some Tests Tests : • • • • •
• •
•
Sitting flexion: Tests sacroiliac dysfunction Standing flexion: Tests iliosacral dysfunction Trendelenberg: Tests strength of gluteus medius. > 15 degree pelvic drop = (+). Hip Drop: Tests lumbar sidebending capability on opposite side Lachman: Tests anterior and posterior Collateral ligament laxity/rupture with knee semi-flexed Allen (modified): Tests ulnar and radial collateral circulation of the hand Finkelstein's: Finkelstein' s: Tenosynovitis of the tendon sheath of the extensor pollicis brevis (De Quervain's disease), at the radial wrist Straight leg raising: Puts tension on the sciatic nerve epineurium from a disk impingement.
RIBS Pump handle: handle: Ribs 1-5; larger "spinotransverse angle", favors motion about a transverse axis. Bucket handle: Ribs 6-10, smaller "spinotransverse angle", favors motion about an AP axis. Treatment Treatment involvi ng musc le energy: energy: • Rib 1: use anterior and middle scalenes • Rib 2: use posterior scalenes • Ribs 3-5 (6): use pectoralis minor Ribs 6-9: use serratus anterior • Ribs 10-11: use latissimus dorsi • • Rib 12: use quadratus lumborum Inhalation restrictions : Equals "exhalation somatic dysfunction", the rib is caught expired, held and stuck down. Note: TREAT UPPER RIB IN RIB GROUP STUCK DOWN Exhalation restrictions : Equals "inhalation somatic dysfunction", the rib is caught inspired, held and stuck up. Treatment involving respiratory cooperation will have operator increasing thorax flexion for pump handle ribs and increasing thorax sidebending for bucket handle ribs as patient exhales. Note: TREAT LOWER RIB IN GROUP STUCK UP Ribs 11 & 12: Eleventh and Twelfth rib motion is caliper or pincher like motion. Inhalation will move these ribs upward and outward. Exhalation will move them downward and inward. The latissimus dorsi pulls the 11th and 12th ribs up, while the quadratus lumborum pulls the 12th rib down.
UPPER EXTREMITY Shoulder has seven articulations (five true and two false): The costovertebral joint of the first rib, the costosternal joint of first rib, the sternoclavicular, acromioclavicular and the glenohumeral joints are all true shoulder joints. The scapulothoracic and suprahumeral joints are false shoulder shoulder joints. joints. Rotator cuff: Mnemonic: SITS muscles for Supraspinatus, infraspinatus, teres minor and subscapularis. Does little rotation, however, stabilizes and maintains glenohumeral joint function, function, especially especially holding head of humerus in glenoid fossa and gliding it inferiorly during abduction.
SITS: SITS: C5 somatic nerve Falling on outstretched hand will tear infraspinatus and teres minor and dislocation humerus posteriorly. Additionally, it will facilitate a posterior radial head dysfunction at the elbow. Also, lateral cord of brachial plexus compromised against coracoid process leading to paralysis or paresis of cuff muscles. Rotator cuff tear tear : Most common tendon torn is supraspinatus. Test: Jobe or Drop Arm. common after age 40 due to lifetime of Gravitational stress on tendon with resultant weaker arterial supply to muscle. Spencer Spencer techniques for s hould er : (for glenohumeral motion restrictions) • Extension “ Every Fine • Flexion Cartoonist • Circumduction • Circumduction with traction Creates, t reates, then hen Abounds Abounds • Abduction Internal rotation In Red • Abduction with traction Abs Abs tracts” • Elbow dysfunction : Hyperpronation of forearm such as a forward fail onto the palm creates a posterior posteri or radial head lesion. Tx: Hypersupinated, extend and thrust radial head anteriorly. Elbow dysfunction : Hypersupination injury, such as falling backward and landing on the palm creates an anterior radial head. Tx: Hyperpronated, flex and thrust radiaI head posteriorly. Remember: Pronation = posterior radial head. Supination = anterior radial head Reciprocal motion of forearm : Abduction of distal ulnar causes medial glide of olecranon and adduction of wrist joint with resulting distal glide of proximal radial head. Wrist dysfunction: dysfunction : Restricted extension due to ventral glide of proximal carpal bones (scaphoid, lunate and triquetral) is most common. Lunate usual trouble maker. Carpometacarpal joint of thumb: Saddle shape, great motion (except axial rotation), therefore susceptible to somatic dysfunction. Other Other carpom etacarpal etacarpal joint s: Somatic dysfunction with dorsal glide. Note: Gliding motions, which are considered minor motions, are the major area of somatic dysfunction in the extremities.
LOWER EXTREMITY Femur: 1/3 length of human body. Has four axes: A-P (abduction 55, adduction 35), transverse (flexion 85-130, extension 35), anatomical longitudinal (along shaft of femur), and functional longitudinal (internal & external rotation: from line imagined from ASIS to patella). Note: Internal rotation of femur equals a relatively shortening of the leg. (Kuchera) Note: External rotation of the femur equals a relatively lengthening of the leg. (Kuchera) Knee dysfunction : Due to restricted gliding motions. Remember 6 glides: Posterior, anterior, medial, lateral and anterior-medial (increased with knee flexion) and posteriorlateral (increased with knee extension). Usual somatic dysfunction of the knee are anteromedial, medial and posterior glide. (Kuchera) An ter io r cruciate ligament : Keeps tibia from gliding anteriorly on femur. (Lachman's test)
ligament : Keeps tibia from gliding posteriorly on femur. Posterior cruci ate ligament Fibular head : Reciprocity of Proximal and distal fibula: External rotation of the tibia and ankle will carry the distal fibula posteriorly and will elevate and glide the proximal fibular head anteriorly." This is the basis for the HVLA thrust with a posterior fibula head. • • • •
Opposite occurs with internal rotation of tibia and inversion of ankle. Plantar flexion of the ankle tends to create a posterior fibular head Dorsiflexion of the ankle tends to create an anterior fibular head Joint configuration of proximal tiblofibula joint is oblique therefore glide is actually posterior-medially, or anterior-laterally.
HVLA treatment for posterior fibular head therefore involves thrusting the proximal fibula head both anteriorly and laterally while flexing the knee, externally rotating the tibia and everting the ankle to engage and breakthrough restrictive glide barrier.
Usual somatic dysfunction of ankle joint occurs in plantar flexion when the talus glides anteriorly, that is ankle is restricted in dorsiflexion and the talus is restricted in posterior glide.
HVLA treatment for anterior talus is "tug" thrust with ankle locked out in dorsiflexion.
Somatic dysfunction of the navicular bone is plantar glide plus internal rotation (about an AP axis) of its plantar surface.
Somatic dysfunction of the cuboid bone is plantar glide plus external rotation (about an AP axis) of its plantar surface.
Somatic dysfunction of cuneiforms is plantar glide.
HVLA treatment for navicular, cuboid and cuneiform is "Hiss Whip Maneuver". You literally whip the tarsals dorsally with thrust contact on plantar surface of foot.
Note: Note: Again, somatic dysfunction of the extremities tends to involve a restriction in gliding motion.
Note: Note: To paraphrase Dr. Korr: In any disease process there will be hypersympathetic tone. If you have a sustained injury in the extremities and develop, say, reflex sympathetic dystrophy, you must treat the cord levels that supply sympathetics to the extremities. Thoracic cord segments T2-8 supply the upper extremity; thoracic cord segments T11-L2 supply the lower extremity.
SUPINATION INJURY OF THE ANKLE Most common form of strain/sprain of the ankle is supination injury. Supination of the ankle involves: ♦ Inversion ♦ Plantarflexion ♦ Adduction Biomechanics Biomechanics of Supination Supination i njury of the Ankle Structures Motion Talus Moves posteriorly Fibular head Moves posteriorly Innominate (via Biceps Femoris) Rotates posteriorly Sacrum Superior oblique axis, usually on the same side of the somatic dysfunction Tibia Anterior medial glide
Femur Navicular Cuboid
Internal Rotation Plantar/Medial Plantar/Medi al glide Plantar/Lateral Plantar/Later al glide
Pronation of the ankle involves: ♦ Eversion ♦ Dorsiflexion ♦ Abduction Inversion sprain affects the anterior talofibular ligament. An eversion sprain affects the deltoid ligament. Ligaments most commonly affected in an ankle sprain are the anterior talofibular, calcaneofibular and posterior talofibular (in this order).
SHORT LEG SYNDROME Heilig formula: Lift required (L) = Sacral base unleveling in inches (SBU) Duration (D) + Compensation (C) Duration:
1 = 1 to 10 years 2 = 10 to 30 years 3 = > 30 years
Compensation:
0 = Sidebending only 1 = Rotation toward the convexity 2 = wedging, altered facets
Example: 50 y.o. patient with a 1/4" SBU for the past 31 yrs with a compensation of rotation toward the convexity, similar to that of a Type I group curve, with no major spinal deformities (no zygopaphyseal or facet deformity, no wedging of the vertebra). SBU = 1/4 " Duration (3) + Compensation (1) ♦
♦
♦ ♦
= 1/16"
If structural short leg (congenital, etc) the ASIS will be low and the medial malleoli high on the side of the short leg. Functional compensation (due to sacral torsion, etc) the ASIS will be higher on the side of the higher malleoli. A higher ASIS in posterior rotation of the Innominate can be related to short leg only if it is compensated. Any sacral base unleveling of greater than 5 mm should be addressed Dropped sacral base will result in a short leg. May use lift therapy to correct the short leg. Use Heilig to determine the lift required.
The side of SBU is the side where the lumbar convexity will be found. This is where the body begins to compensate. ♦ The final analysis for a heel lift will be different by a 50 to 75% less than the original X-Ray findings. This is due to X-Ray distortion of bone size. ♦ Pelvis rotates and sideshifts towards the long leg side ♦ There is an increase in the lumbosacral angle of 2 to 3 degrees ♦ The shoulder will be low on the opposite side of the SBU Fragile/Acu te pain/Aged, osteoporosis: 1/16" q 2 wk. Do not start with more than ♦ Fragile/Acute 1/16" ♦ Patient is stable: 1/8" q 2 wk ♦ Sudden loss (Acute fracture): restore full amount/length, this is to prevent compensation by the body. ♦ Up to1/4” replaceable heel lift can be used inside the shoe ♦ Up to1/2" total heel lift can be placed between the heel of the patient’s foot and the floor. This can be 1/4" inside the shoe & 1/4" to the heel of shoe. Not more than 1/4” of the total heel lift can be placed inside the shoe. ♦ An increase beyond a 1/2” heel lift must be added to the heel and to the anterior half sole. Ex: If heel had been lifted 1/2” and an increase of 1/4” was required: 1/4” would be added to the heel and 1/4” to the anterior half sole. ♦ Heel lift rotates pelvis opposite side ♦ Sole lift rotate pelvis same side ♦ Therefore if lift > 1/2" need half sole ♦ Lift therapy will elevate the lower extremity and sacral base and also rotate the pelvis to the opposite side. This rotation of the pelvis needs to be addressed when the lift is > 1/4". In this case you need an anterior half sole to help bring back the pelvis to midline. ♦
PSOAS SPASM ♦
♦ ♦
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♦
A psoas spasm will give you a non-neutral (Type II, flexion or extension) somatic dysfunction at L1 and L2. The psoas originates from T12-L5 and inserts into the lesser trochanter of the femur Somatic nerves to the psoas are T12-L3. A psoas spasm can cause a contralateral piriformis spasm leading to a piriformis syndrome with pain referral to the L2 range. The nerve supply to the piriformis is S2. A spasm of the piriformis will be the cause of an Inferior pole in a sacral torsion. The spasm anchors the inferior pole of the oblique axis. Sidebending of the lumbar spine will anchor the superior pole of the oblique axis. The psoas can go into spasm in a patient that is passing a renal stone through the ureters. Psoas spasm may also affect ureteral function since the ureters descend on the fascia of the psoas.
SPECIFIC MUSCLE ACTIONS Muscle Suboccipital muscles Intertranversarii Rotatores Brevis Splenius Trapezius Semispinalis Longissimus
Acti Ac ti on Extends and rotates head to same side Bends column to same side Rotates column to opposite side Extends, sidebends & rotates to same side Extends & sidebends toward; rotates away Extend and rotate to opposite side Extends, sidebends & rotates to same side
**Erector Spinae: Iliocostalis, longissimus & spinalis
RANGE OF MOTION BY REGION Region
Range Range of Motion
Cervical
Muscles
Flexion - 45 degrees Extension - 90 degrees Sidebending - 45 degrees Rotation - 90 degrees
Thoracolumbar
SCM/Scaleni SCM/Scale ni Trapezius/Spleni/Erector Trapezius/Spl eni/Erector Spinae SCM/Scaleni/Spleni/ES SCM/Scaleni /Spleni/ES SCM/Scaleni/ES/Spleni SCM/Scalen i/ES/Spleni *SCM & Scaleni rotate opposite Flexion - 45 degrees Rectus Abdominis/psoas Extension - 45 degrees Erector Spinae Sidebending - 45 degrees ABS/ES/Quadratus ABS/ES/Q uadratus Lumborum/psoas Rotation - 45 degrees Obliques/ES
REMEMBER: Range REMEMBER: Range of motion only comprises 1/4 th of somatic dysfunction!!! T.A.R T.A.R.T. Try to alleviate and improve the others.
GATE THEORY THEORY OF OF WALL WAL L A ND MELZA MELZACK CK According to this theory, the substantia substantia gelatinosa gelatinosa acts as a gating mechanism for the control of afferent input to the spinothalamic neurons. The activity in pain carrying slow, small unmyelinated C fibers keep the gates open and activation of fast, large myelinated A delta fibers closes closes the gate. gate. Impulses carried carried by the larger larger faster fibers fibers are thought thought to cause synaptic inhibition of the tracts carrying pain perception (C fibers). Under this gate control theory, on the basis of all afferent stimuli, the neurons of the spinal cord would decide whether or not a particular event should be reported to the brain as being painful. The spray and stretch technique for the treatment of trigger points is believed to act through this theory. "The vapocoolant or TENS unit activates cold sensitive receptors
which report centrally via fast fibers. The afferent volley conveyed through these fast fibers blocks the trigger point nociceptive impulses transmitted by slow fibers at the substantia gelatinosum (lamina 5). This allows the operator to stretch the muscle containing the trigger point without pain or reflex spasm."
Coolant Spray(or TENS)
Deep pain is blocked
Krause fibers
Muscles can be stretched and reset
Gate is blocked(dorsal horn)
PAIN Fast fibers ascend the cord via the neospinothalamic tracts (new). Slow fibers ascend the cord via the paleospinothalamic tracts (old). The fibers enter the dorsal horn, may ascend or descend a few segments, synapse at the substantia gelatinosa which precedes the posterior grey matter, then cross over the cord to ascend ultimately to among other areas the thalamus (and periaquaductal grey matter of the ventricles) and cortex. Pain from the viscera is transmitted via the sympathetic nerves. Exceptions include the cervix, upper vagina, bladder trigone, prostate and the esophagus, trachea, and main bronchi, which transmit pain via the parasympathetics (2). Remember, however, that there are no parasympathetic fibers in the extremities. Autonomic mediated pain from an extremity (reflex sympathetic dystrophy) is the result of sympathetic activation and During inflammation of an organ, the appendix for example, pain is first recorded in the “visceral layer” which obviously refers pain to the embryological origin (around the umbilicus) then inflames the “parietal layer” (and peritoneum) which stimulates the somatic nerves which are dermatomally related, in this instance to the right lower quadrant of the abdominal wall. Thusly the pain of appendicitis “moves” because of different neural activation; first the visceral then somatic. In addition, the organs are insensitive to burning, cutting, heat and cold but are sensitive to traction, distension, anoxia or contractions.
FIBROMYALGIA Pathogenesis and Clinical Presentation: Largely unknown. Look for a preceding traumatic event. Abnormal levels of serotonin and norepinephrine and substance P. Disturbances of stage 4 (non-rapid eye movement, non-REM). Female, pain, stiffness and fatique. Total body pain for greater than 3 months in at least 11 of 18 areas: 1. Occiput, suboccipital mm 2. Low cervical, anterior intertransverse process space C5-7 3. Trapezius 4. Suprapinatus 5. Second rib at costochondral junction 6. Lateral epicondyle 7. Gluteals 8. Greater trochanter 9. Knee (medial knee fat pad) Note: 9 areas bilaterally equals 18 total. You need at least 11 of the above (bilaterals count for two areas) to secure a diagnosis of Fibromylagia. In addition, axial spinal pain is important as Is having pain in 3 of the four quadrants of the body; ie, “my right arm, back and both lower extremities hurt all the time.” Treatment includes Cardiofitness
OMT,
Tricyclics,
SSRI’s,
Cognitive
Behavioral
Therapy,
MISCELLANEOUS TIDBITS 1st rib: most dysfunctions are of exhalation restriction. Rib is stuck up. ♦ In a question regarding scoliosis that only refers to the side of the convexity of the curve, this will indicate the side of the rotation. Sibebending will be opposite. Ex: convexity to the right = rotated right, sidebent left. ♦ Piriformis tenderpoint for counterstrain is between the PSIS and the Greater Trochanter. ♦ L5 nerve root supplies motor innervation to the extensor hallicus longus. ♦ Muscles of the Pelvic Diaphragm = Levator Ani and Coccygeus. The innervation is from S2-S4 th rib. Important ♦ The first rib that you feel below the tip of the scapula is the 8 landmark for centesis of the pleura. ♦
