Download Client Seated - The Littered Box

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The client is supine with the head and neck contralaterally rotated; you are seated at the head of
the table. Before palpating, first visualize the contraction of the SCM as the client lifts the head
from the table. Then palpate the contraction of the SCM just superior to the sternoclavicular
joint as the client again lifts the head from the table. Once felt, continue palpating the SCM to
the mastoid process of the temporal bone and the superior nuchal line of the occipital bone by
strumming perpendicular to the fibers as the client alternately contracts and relaxes the muscle.
Note: Look and palpate carefully for the clavicular head; it is usually less obvious than the
sternal head.
2.
The client is supine; you are seated at the head of the table. Locate the lateral border of the
clavicular head of the SCM (be sure that it is the lateral border of the clavicular head, not the
sternal head that you have located). Place palpating fingers just lateral to the lateral
border of the clavicular head of the SCM and just superior to the clavicle, and feel for the
contraction of the scalenes as the client takes in short, quick breaths through the nose.
Once felt, palpate as much of the scalenes as possible in the posterior triangle of the neck by
strumming perpendicular to the fibers. The transverse processes attachment of the scalenes can
usually be palpated by pressing in deep to the SCM if it is first slackened by passively flexing
and ipsilaterally laterally flexing the client's head and neck.
Note: It can be challenging to discern the anterior, middle, and posterior scalenes from each
other. The best way to achieve this is to try to feel for the different direction of fibers that each
one has. Remember: the anterior scalene goes to C3-C6; the middle scalene goes to C2-C7; and
the posterior scalene goes to C5-C7. Also, keep in mind that the posterior scalene is located in
the posterior triangle of the neck immediately anterior to the upper trapezius and levator
scapulae.
3.
The client is supine; you are seated at the head
of the table. Locate the medial border of the sternal head of the SCM, and then drop off it and
place palpating fingers immediately medial to that. Sink in toward the anterior surface of the
vertebral bodies slowly and gently, but firmly. If you feel a pulse under your fingers,
move your fingers to one side or the other and continue palpating for the vertebral bodies. Once
you have reached the vertebral bodies, confirm that you are on the longus colli by asking the
client to flex the head and neck by lifting the head up off the table. Palpate as much of the
longus colli and capitis as possible superiorly and inferiorly by strumming perpendicular to the
fibers.
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Note: The carotid tubercle on the transverse process of C6 (see page 100) is a good landmark for
determining the segmental level of the palpating fingers.
4.
For the purpose of palpation, the hyoid group can be divided into the
infrahyoid group and the suprahyoid group. The client is supine; you are seated at
the head of the table. To palpate the infrahyoids, place your palpating fingers immediately
inferior to the hyoid bone and just off center and feel for their contraction as
the client is resisted from depressing the mandible at the temporomandibular joints (TM)s).
Once felt, palpate these muscles toward their inferior attachments on the sternum
by strumming perpendicular to the fibers as the client alternately contracts and relaxes them.
The inferior belly of the omohyoid can be palpated in the posterior triangle of the neck by
strumming perpendicular to it as the client is resisted from depressing the mandible at the
TMJs.
To palpate the suprahyoids, place your palpating fingers immediately inferior to the mandible
and again feel for their contraction as the client is resisted from depressing the mandible at the
TMJs. Once felt, palpate these muscles toward the hyoid bone by strumming perpendicular to
the fibers as the client alternately contracts and relaxes them. Palpate the stylohyoid and
superior belly of the digastric by strumming perpendicular to their fibers from the hyoid
bone toward the mastoid process of the temporal bone as the client alternately contracts and
relaxes them.
5.
The client is seated with the head and neck contralaterally rotated;
you are standing to the side of the client. Feel for the contraction of the upper trapezius at the
top of the shoulder as the client is resisted from extending the head and neck against the
resistance of your support hand on the back of their head (Note: The contraction of the upper
trapezius is often visible and palpable; be sure to look for it as well). Continue palpating the
upper trapezius toward its medial attachment on the head and neck and its lateral attachment
on the lateral clavicle and acromion process by strumming perpendicular to its fibers as the
client alternately contracts and relaxes it.
Note: The superior aspect of the upper trapezius is actually quite narrow and only attaches to
the medial V3 of the superior nuchal line of the occipital bone.
6.
Note: The palpation of the levator scapulae can be divided into
three parts: when it is deep to the upper trapezius near its scapular attachment, when it is
superficial in the posterior triangle of the neck, and when it is deep to the SCM near its spinal
attachment. The client is seated with the hand in the small of the back; you are standing behind or to the side of the client. Locate the superior angle of the scapula and place your
palpating hand immediately superior and medial to it. Feel for the contraction of the levator
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scapulae deep to the upper trapezius as the client performs a gentle, short range of motion of
elevation of the scapula at the scapulocostal joint. Once felt, continue palpating it until it enters
the posterior triangle of the neck (i.e., until it is no longer deep to the upper trapezius) by
strumming perpendicular to its fibers as the client alternately gently contracts and relaxes the
muscle. Once the levator scapulae is located in the posterior triangle, it is superficial and easily
palpable, and sometimes visible as well. It is no longer necessary for the client to have the hand
in the small of the back, and the client can be asked to perform a more forceful contraction
(against resistance if desired) of elevation of the scapula. Continue palpating it superiorly by
strumming perpendicular to its fibers as the client alternately contracts and relaxes the muscle.
As it approaches its spinal attachment (transverse processes of C1-C4), the levator scapulae will
go deep to the SCM. To palpate it all the way to its spinal attachments deep to the SCM, the
SCM must be slackened by passively moving the client's head and neck into flexion and
ipsilateral lateral flexion. Note: When following the levator scapulae superiorly, be sure that
you follow it toward the transverse process of Cl, which is located more anteriorly than most
people realize; the transverse process of Cl is located immediately inferior to the ear.
7.
The client is seated with the head and neck ipsilaterally rotated;
you are standing behind the client. Palpate in the uppermost aspect of the posterior triangle of
the neck, just inferior to the occiput and posterior to the SCM. Now feel for the contraction of
the splenius capitis as the client is resisted from extending the head and neck at the spinal joints.
Once felt, strum perpendicular to its fibers and try to follow it inferiorly as the client alternately
contracts and relaxes the muscle. Once you are no longer in the posterior triangle of the neck,
the splenius capitis can be palpated two ways: (1) feel for it through the upper trapezius by
asking the client to extend the head and neck against gentle resistance; once felt, try to follow it
as far inferiorly as possible; or (2) feel for it directly: this requires you to palpate deep (anterior)
to the border of the upper trapezius and press anteriorly toward the upper thoracic spinous
processes by reaching with your palpating fingers between the upper trapezius and the splenius
capitis. To accomplish this, it is best to stand more to the front of the client so that your finger
pads are oriented anteriorly toward the splenius capitis. Furthermore, it is important that the
upper trapezius is relaxed and slackened; it can be slackened by passively moving the client's
head and neck into extension, contralateral rotation, and/or ipsilateral lateral flexion.
8.
The client is supine with the hand in the small of the back,
and/or the head and neck rotated to the same side (ipsilaterally rotated); you are seated at the
head of the table. Ask the client to extend the head and neck at the spinal joints by gently
pressing the head into the table and feel for the contraction of the Semispinalis capitis deep to
the upper trapezius, just below the occiput and just lateral to the spine. Once felt, continue
palpating the semispinalis capitis inferiorly as far as possible as the client alternately contracts
and relaxes the muscle.
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9.
The client is supine; you are seated at the
head of the table. Begin by palpating the RCPMaj; palpate just superior and slightly lateral to
the spinous process of C2 and strum perpendicular to it fibers. Once felt, continue palpating the
RCPMaj to the occiput by strumming perpendicular
to its fibers. Palpate the RCPMin in the same manner by strumming perpendicular to it,
beginning just superolateral to the posterior tubercle of Cl. Once felt, continue palpating the RCPMin to the occiput by strumming perpendicular to it. To palpate the OCI, palpate
between the spinous process of C2 and the transverse process of Cl, strumming
perpendicular to the fibers. It may be helpful to have the OCI contract by gently resisting the
client from ipsilaterally rotating the head. The OCS is extremely challenging to palpate and
discern from adjacent musculature. To attempt its palpation, feel for it just lateral to the
superior attachment of the RCPMaj; if felt, try to continue palpating it inferiorly
by strumming perpendicular to it.
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