Download OMM TEST – STUDY GUIDE BLOCK 5 LECTURE 1

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OMM TEST – STUDY GUIDE BLOCK 5
LECTURE 1 – Williams Lumbar Review
Distinguish structural anatomy from functional anatomy of the lumbar spine.
I.
II.
III.
Interconnectivity (Lumbar aponeurosis and fascia) Allows functional attachments to:
a. Gluteal mm, Hamstrings, Iliotibial band to lower extremity, UE via latissimus dorsi mm, Diaphragm,
Pelvis
Embryo Stuff
a. Somites
i. dorsal mesoderm on either side of notochord
ii. arranged in pairs: 4 occipital, 8 cervical,
iii. 12 thoracic, 5 lumbar, 5 sacral, 8-10 coccygeal
b. Sclerotome
i. 1st significant change in somite of human embryo
ii. cluster of mesenchymal cells
iii. aggregate around notochord to give rise to vertebral column and ribs
iv. clustering of sclerotomal cells on either side of notochord give rise to body or “centrum of
vertebrae”
v. paired mesenchymal cells extend:
1. dorsally- primordium of neural arch
2. laterally- costal processes
c. Dermatome – area of skin supplied by cutaneous braches from a single spinal nerve.
d. Myotome – portion of mesodermal somite that gives rise to skeletal muscle.
e. Sclerotome – group of mesenchymal cells of the somite (located on each side of the notochord) that
become centrum of vertebrae and ribs. Also become joint capsule, ligaments, & bone.
Functional Anatomy
a. Vertebral Body
i. Large cross-sectional area
ii. Longitudinal and vertical trabecular arrangement
iii. Sustain heavy, functional longitudinal loads
iv. 2 short stubby transverse processes (from the costal processes embryologically)
v. No costal facets
vi. No foramina in transverse processes (Where do we see foramina In the transverse
processes?C1&C2)
vii. Vertebral body higher in front than back
viii. Hematopoiesis
b. Intervertebral Disc
i. total: ¼ length of spine
1. nucleus pulposus-compressible, 70-90% water (comes from ectoderm tissue)
2. annulus fibrosus -thick anteriorly, thin posteriorly; holds nucleus and gives form to it
(comes from mesoderm tissue)
ii. most common areas of rupture: L4/L5; L5/S1
c. Pedicles
i. connect post elements to vertebral body
ii.
lumbar nerve winds around the pedicles, then exist intervertebral foramen before it crosses
disc.
iii.
AP Radiograph: Pedicle- 2 longitudinal rows of opaque ovals.
d. Transverse Processes
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IV.
V.
i. Long, thin
ii. Directed laterally in horizontal plane
iii. In same plane as corresponding spinous process.
e. Superior and Inferior Articular Processes
f. Intervertebral Foramen
g. Lamina
i. Project medially and caudad from pedicle
ii. End to form the spinous processes
iii. CLINICAL - “Spina bifida”
1. Lamina do not completely meet to form SP
2. Opening where SP should be
iv. Know spina bifida, meningeocele (just dural sac sticks out, is empty), myelomeningocele
(contains nerves).
h. Spinous Processes
i. Larger
ii. Quadrangular (spade-shaped)
iii. Directed dorsally in horizontal plane
i. Spinal Canal
i. Wider transversely than AP
ii. Spinal cord
iii. Ends L2-L3, becomes “cauda equina”
Bony Asymmetry
a. 30-40% of the population have congenital osseous asymmetry
i. Facet asymmetry = MOST COMMON..one facet in a diff plane
ii. Sacralization (batwing deformity…partial fusion of L5 to sacrum)
iii. Lumbarization (sacrum splits and looks like lumbar, S1 becomes an L6)
iv. Spina bifida occulta
b. Stress Fx of Pars Interarticularis
i. “Spondylolisis” – collar on scotty dog, defect in pars interarticularis
ii. “Spondylolisthesis” – forward slippage of vertebrae...bilateral spodylolysis causes it
c. “scotty dog” =
i. ear – superior articular process
ii. eye – pedicle
iii. nose – transverse process
iv. foreleg – inferior articular process
v. hindleg – spinous process
vi. head – transverse process
vii. body – spinous process & lamina
Muscles
a. Dipahrgam
i. R crus L1-L3, L crus L1-L2
b. Psoas
i. origin: ant portions of lumbar vertebrae near insertion of crura
ii.
inserts: with iliacus as “iliopsoas” into Lesser Trochanter
iii.
Major role in synergistic activities of low back mm in maintaining normal LS
angle
and proper postural balance.
c. Quadratus lumborum
i. Attachments: 12th rib – functions with respiration, Iliac crest, Vertebral column
ii. Motion
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1. Bilateral contraction – extension
2. Unilateral contraction – extension + sidebending
d. Latissimus dorsi
i. Originates on Spinous processes of T7-T12
1. Thoracolumbar fascia of the spinous processes of all lumbar vertebrae and the sacrum
2. Posterior 1/3 of iliac crest
3. 9th-12th ribs
4. Inferior angle of scapula
ii. Inserts on Crest of the lesser tuberosity of humerus
iii. Action: raises body to arms during climbing, IR, Adduction, respiration(expiration/cough)
iv. Innervation: Thoracodorsal nerve (C6-8)
e. Gluteus maximus
i. Originates in Thoracolumbar fascia, posterior ilium, and on dorsal sacrum
ii. Inserts on Iliotibial band and femur(gluteal tuberosity)
iii. Extension & External rotation of hip and stabilizes torso (some abduction & adduction)
iv. Innervation: Inferior Gluteal nerve (L5,S1-2)
f. Erector Spinae
i. Large deep mm lying of each side of SP
ii. Iliocostalis, longissimus, spinalis
iii. Bilateral contraction-extension
iv. Unilateral contraction-extension +sidebending
v. “ I LOVE SPAGHETTI” (Lateral to Medial)
g. Multifidus & Rotatores
i. Smaller mm
ii. Deeper that erector spinae
iii. control motion of individual vertebrae (ME!)
Identify landmarks and anatomical structures of the lumbar spine and describe how they correlate to the supporting
structures (ligaments, muscles, vasculature, and nerves).
I.
II.
III.
Developmental Curves
a. Cervical curve - Develops as the child begins to hold its head up
b. Lumbar curve - Develops as the child begins to stand and walk
i. “Lumbar Lordosis”
1. Backward bending curve
2. Functionally permits more extension than flexion
3. Normally can flex 40 degrees, extend 30 degrees. Greatest amount of motion is in
sagittal plane!
4. *Large portion of low back pain is from lordosis
a. “Sagittal Plane Somatic Dysfunction”
IV Discs and deficit  X + 1 rule
a. Herniation at disc X affects nerve root X+1
b. Nerve root X will have already exited the foramina and will be unaffected
Structural Integrity maintained by
a. ALL – limits extension
i. C2 to sacral base; broader and thicker than Posterior Longitudinal ligament
b. PLL – narrow
i. Continuous from C spine to L spine; Narrows as it reaches the L spine; makes posterolateral
portion vulnerable to disc herniation.
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c. Iliolumbar ligaments
i. Attachment at L4 and L5 transverse process
ii. Increase stability at the lumbosacral junction
iii. Commonly strained in traumatic injuries
iv. One of the 1st areas to become tender with postural stress and decompensation. “ I think I have
a hernia.”
Outline a physical examination and osteopathic approach to a patient with low back pain.
I.
II.
III.
IV.
V.
Possible GI influence
a. Increased Sympathetics
i. Ileus
ii. Constipation
iii. Abdominal pain
iv. Flatulence
v. Distension
b. Increased Parasympathetics
i. Colitis
ii. Crohn’s
iii. IBS (both inc.)
iv. Diarrhea
v. Vomiting
GI Chapman’s points
a. Lower GI (Anterior)
i. Large Intestine (Lateral thigh)
ii. Rectum
1. SNS: T10-L2
2. PNS: Vagus & Sacral Plexus
GU Chapman’s points
a. Male
i. Kidney: L1
ii. Bladder: TP L2
iii. Urethra: TP L3
b. Female
i. Uterus on ramus
ii. Ovaries, urethra on symphysis
iii. Ovary (T10 TP)
iv. Fallopian
v. Uterus (L5 TP)
vi. Vagina
Reflexes
a. L4
5
i.
ii.
iii.
iv.
Patellar Reflex
Quadriceps, Tibialis anterior (inversion)
Sensation medial aspect of leg and foot
Medial patella up to base of Great toe
i.
ii.
iii.
iv.
No reflex
Dorsiflexion 1st Great Toe (extensor hallucis)
Sensation lateral side of leg & dorsum of foot
“heel walk”
b. L5
c. S1
i. Achilles reflex
ii. Peroneus longus and brevis mm strength
iii. Eversion to test mm strength
iv. Sensation along lateral aspect of foot
v. “Toe Walk”
d. Babinski
i. Positive = upper motor neuron problems
1. Cortical
2. Subcortical (internal capsule or brainstem)
3. Spinal cord
Recognize the different types of presentation of lumbar somatic dysfunction.
I.
II.
III.
Straight Leg Raise Test
a. Step 1 (Lasegue’s test)
i. Raise affected leg until pain is experienced
ii. If pain begins <70° flexion go to step 2
b. Step 2 (Braggard’s test)
i. Lower leg 5° and add foot dorsiflexion
ii. pain elicited by dorsiflexion indicates nerve root irritation
Thomas Test to dx Psoas
a. Flex one thigh up to abdomen
b. Considered positive if opposite knee lifts off table
c. Can be active or passive
d. Big distance = restriction in hip extension
Hip Drop Test
a. screens for the ability of the lumbar and lumbothroacic region to sidebend away from the side of the hip
drop
b. pt stands with doc seated behind pt
c. doc places fingers on superior and lateral surface of iliac crest with palms facing floor
d. pt is told to bend one knee without lifting his/her heel off the floor and allowing the hip to drop
downward.
e. note the change in levelness of the horizontal plane (Normal hip drop is 20-25 degrees), look for smooth
lumbar curve
f. Positive = the plane of the iliac crests drops less than 20 degrees and/or the lumbar and thoracolumbar
spine does not side bend with a smooth lateral curve; named to the side that is weight bearing (Ex: L leg
bends and L crest does not drop: Positive R hip drop : restriction to SB
g. Positive test suggests that T-L and/or lumbar spine has difficulty SB toward the weight bearing side.
Use the proper nomenclature and shorthand notation for lumbar spine somatic dysfunction.
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I.
II.
Remember Fryette’s
a. 1st Principle - When sidebending is attempted from neutral (anatomical) position, rotation of vertebral
bodies follows to the opposite direction.
b. 2nd Principle- When sidebending is attempted from non-neutral (hyperflexed or hyperextended)
position, rotation must precede sidebending to the same side.
c. 3rd Principle - Motion introduced in one plane limits and modifies motion in the other planes.
Diff b/t physiologic findings and somatic dysfxn?
a. Physiologic motion becomes somatic dysfunction if the segments do not return to “normal” after
completion of motion. They may be pure sagittal plane dysfunctions, neutral dysfunctions, or flexed or
extended non neutral dysfunctions.
Review and discuss the indications and contraindications for HVLA to the lumbar spine.
I.
II.
III.
IV.
Definitions
a. HVLA (thrust) approach is characterized by positioning to engage the restrictive barrier, followed by a
corrective maneuver to move through the barrier.
b. Accurate diagnosis is the key to performance of HVLA (thrust) techniques.
c. Positioning against the restrictive barrier in all planes is followed by a rapid and brief corrective thrust.
d. HVLA (thrust) techniques can be taught and learned easily. The necessary motor coordination for
effective use requires extensive practice and experience.
e. “An osteopathic technique employing a rapid, therapeutic force of brief duration that travels a short
distance within the anatomic range of motion of a joint, and that engages the restrictive barrier of an
articular somatic dysfunction in one or more planes of motion to elicit release of restriction. Also know
as thrust technique.”
Has
a. Distinct barrier mechanics
b. Within anatomic ROM (actually physiologic ROM)
c. Engages restrictive barrier (within physiologic ROM)
d. Goal: 1. move restricted joint through its dysfunctional barrier. 2. restore appropriate physiologic
motion to the dysfunctional joint.
Steps to HVLA Thrust
a. Gently position patient against restrictive barrier.
b. Apply constant gentle pressure against barrier.
c. Encourage patient to breathe and relax.
d. Apply a gentle high velocity, low amplitude thrust through restrictive barrier.
e. Reposition patient to neutral position and reassess.
Contraindications to HVLA
a. Absolute (regionally or segmentally specific:
i. Upper Cervical (OA, AA)
1. Rheumatoid Arthritis
2. Down Syndrome
3. Achondroplastic dwarfism
4. Chiari malformation
5. Vertebrobasilar insufficiency
ii. Fracture / Dislocation / spinal or joint instability
iii. Ankylosis / Spondylosis with fusion
iv. Surgical fusion / ankylosis/ spondylosis with fusion
v. Klippel – Feil Syndrome
vi. Inflammatory Joint Disease
vii. Joint Infection
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III.
viii. Bony Malignancy
ix. Patient Refusal
b. RELATIVE CI to HVLA
i. Acute HNP (herniated nucleus pulposus)
ii. Acute Radiculopathy
iii. Acute whiplash / severe mm spasm / sprain / strain
iv. Osteopenia / Osteoporosis
v. Spondylolisthesis
vi. Metabolic Bone Disease
vii. Hypermobility
Lumbar Roll for Neutral (HVLA) Somatic Dysfunction & Treatment of Non-neutral Lumbar Somatic
Dysfunction: Articulatory
a. Keys to Lumbar Roll
i. Correct diagnosis!
ii. 3 plane localization to the interspace
ABOVE the lesioned segment
iii. Get your weight over your caudal forearm
iv. Lockout at all barriers
v. Thrust in sidebending-rotation (sup./cephalad, anterior and medially)
Lecture 2 – Lumbar: Indirect (Slater) – 1 question will be from the reading
I.
II.
III.
Incidence of Low Back Pain
a. 85 % of the general population will have low back pain (LBP)
i. Most common reason to see a physician for musculoskeletal condition
ii. Second most common pain complaint
iii. 35% of adolescent athletes
iv. 27 % LBP in adults is MS strains
v. Overuse injuries are prone to recurrence
vi. 26% males/33% females
b. Risk regardless of sex, age, occupation, etc.
c. Medical Expenditure Panel Survey (MEPS)
i. Costs inc 65% from 1997-2005 to $86 billion
ii. Avg cost of single work related back injury is over $8000
iii. Adults with functional limitations inc by 19%
See reviews of NSxRy and E/F SxRx (slides for each to review terminology)
a. Potential test types question: 46 yo has low back pain, no radicular, you put them into Ext and L thumb
is post and inferior…how would you tx w/ an indirect tx?
Facilitated Postional Release (FPR)
a. Neurophysiology
i. “immobility of a lesioned segment was initiated or maintained by an increased gain in gamma
motor neuron activity of that segment” - Korr.
ii. “an inappropriately high gain-set of the muscle spindle results in changes characteristic of
somatic dysfunction” - Bailey.
iii. TEST QUESTION FROM ANY OF THIS IN BOLD:
iv. primary neurophysiologic mechanism affected by FPR is thought to be the relationship
between Iα-afferent and γ-efferent activity
v. If the dysfunctional segment is positioned appropriately, the fibers may return to normal
length, which decreases tension in the fibers
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IV.
vi. This reduced tension in the area of the muscle spindle eliminates the afferent excitatory
impulses
vii. This “quiets” the hyperactive gamma motor gain, reducing the stretch stimuli, and eliminates
the reflex activation of the α-motor neuron
viii. This allows the tension and hypertonicity of the muscles to “reset”
ix. Think: afferents, efferents, gamma gain
1. Shorter than counterstrain (which is like 90 - to 120- sec vs FPR 3-5 sec)
b. Benefits
i. Easily Applied
ii. Non-traumatic
iii. Effective & Efficient
iv. When performed properly patients report immediate relief of point tenderness/pain.
c. Tx is classified into 2 categories
i. one directed at normalization of palpable abnormal tissue texture
ii. to influence deep muscle involved in joint mobility
d. Tx’s on ppt slides..from lab
i. Lumbar Soft Tissue
ii. Lumbar Flexion
iii. Lumbar Extension
iv. There are prone and seated tx, seated is prolly easier to work with
e. INDICATION = myofascial or articular somatic dysfxn
f. RELATIVE CONTRAINDICATIONS (no true absolute indications)
i. Moderate to severe joint instability
ii. Herniated disc where the positioning could exacerbate the condition
iii. Moderate to severe intervertebral foraminal stenosis, especially in the presence of radicular
symptoms at the level to be treated if the positioning could cause exacerbation of the symptoms
by further narrowing the foramen
iv. Severe sprains and strains where the positioning may exacerbate the injury
v. Certain congenital anomalies or conditions in which the position needed to treat the
dysfunction is not possible (e.g., ankylosis)
vi. Vertebrobasilar insufficiency
JONES STRAIN/COUNTERSTRAIN
a. Neurophysoiology
i. As with FPR, the primary neurophysiologic mechanism affected by counterstrain is thought to be
the relationship between Iα-afferent and γ-efferent activity
ii. If the dysfunctional segment is positioned appropriately, the fibers may return to normal length,
which decreases tension in the fibers
iii. This reduced tension in the area of the muscle spindle eliminates the afferent excitatory
impulses
iv. This “quiets” the gamma motor gain, reducing the stretch stimuli, and eliminates the reflex
activation of the α-motor neuron
v. This allows the tension and hypertonicity of the muscles to “reset”
b. Tender point
i. Small edematous area roughly the size of a fingertip
ii. Painful to palpation
iii. Anterior or posterior
iv. Located at:
1. Bone-tendon junction
2. Musculotendonous junction
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3. Body of the muscle
4. Related dermatome
v. Usually located in the body of the antagonistic muscle (hyper-shortened muscle)
c. Essentials
i. Use Flexion or Extension (translate to localize)
ii. Have tender point at the apex of the curve
iii. SB & R according to Rx formula (for Type I and Type II dysfunctions - remember this is indirect)
iv. Shutdown the tender point at least 70%
1. This position is called the position of comfort (subjective) or mobile point (objective)
v. Tender point: Maintain light contact
vi. Hold positioning & tender point for:
1. 90 seconds: everything except ribs
2. 120 seconds: Ribs
vii. Recheck tenderness during treatment
viii. If you feel a therapeutic pulse fine tune your position
ix. Slowly reposition the patient and don’t let them reposition themselves!!!
d. Anterior Lumbar Joint’s Points
i. Tender points ASIS L1, AIIS L2-4, PUBES L5
V.
e. Posterior Lumbar Jones points
f. Board Strategy for Counterstrain
i. IS THE T.P AN ANTERIOR OR POSTERIOR POINT
1. IF ANTERIOR = FLEXED
2. IF POSTEROR = EXTENDED
ii. T.P. IS OVER THE OPEN FACET PAIR [ RIGHT ]
1. THEN ANTERIOR Dx = FRSL
2. THEN POSTERIOR Dx = ERSL
iii. FOR THE S/CS POSITIONING, PUT IN THE POSITION OF THE POSITIONAL
DIAGNOSIS TO
SHUT DOWN THE TENDER POINT
PIRIFORMIS SYNDROME
a. What
i. Neuromuscular condition characterized by hip and buttock pain
ii. Most frequently during the 4-5th decades
iii. Incidence rates among patients with low back pain vary widely, from 5% to 36%
iv. Muscle acts as an external rotator, weak abductor, and weak flexor of the hip. Provides postural
stability during ambulation and standing
v. Attachments:
1. Anterior surface of the sacrum
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VI.
2. Attaches to the superior medial aspect of the greater trochanter
vi. This syndrome is often overlooked in clinical settings because its presentation may be similar to
that of lumbar radiculopathy, primary sacral dysfunction, or innominate dysfunction
b. Causes
i. May have a peripheral neuritis of the sciatic nerve caused by an abnormal condition of the
piriformis muscle Symptoms:
1. Pain with sitting, standing, lying >15 min
2. Pain and/or paresthesia buttocks, may radiate down posterior leg, usually stopping
above the knee
3. Pain with rising from seated position
4. Pain worse with internal rotation of leg
5. Pain improves with ambulation
ii. Microtrauma
1. “Wallet Neuritis”
2. Toilet sitting
iii. Macrotrauma
1. Fall
2. Injection complication
iv. Ischemia
v. Biomechanical
1. Postural
2. Somatic dysfunction
c. S/Cs
i. Tenderpoint is usually in the belly of the muscle
ii. Location can be found 1/2 the distance between Sacral base and ILA, then 1/2 the distance
between this point and the Greater Trochanter
d. Counterstrain
i. With patient prone locate and monitor the tender point
ii. flex the hip on the dysfunctional side to ~135*,
iii. while monitoring the tender point add external rotation and ABduction until you achieve a 70%
reduction in pain
iv. Hold for 90 seconds then return to neutral
v. Recheck
PSOAS Syndrome
a. What
i. Psoas syndrome is a neuromuscular condition characterized by pain in lower back and may
radiate to hip or groin
ii. Cause by muscle dysfunction due to spasm or strain
iii. Shortened muscle (i.e. sitting for prolonged period; running hills, sit ups with legs extended)
iv. Organic causes (malignancy, AAA, abscess, appendicitis, hernia, prostatitis, diverticulitis, OA)
b. Causes
i. Flexion deformity of leg
1. + Thomas test
ii. Leg length discrepancy
1. Short leg on dysfunctional side
iii. Lumbar lordosis
iv. Spasm of contralateral piriformis
v. Pelvic shift to opposite side
vi. Lumbar dysfunction
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VII.
1. Typically flexion dysfunction of L1 or L2
2. Compensatory extension dysfunction in L-S spine
vii. Sacral dysfunction
1. Rotate away from dysfunctional side
c. Maverick Points
i. Roughly 5% of counterstrain tender points will not respond to the typical pattern of treatment
(maybe just putting in position of ease to relax the TP and tx it there)
ii. Try putting the patient in the opposite position and treating the tender point
Or
iii. Put the tender point in it’s position of ease and treat it
Summary of Point Types
Lecture 4: Osteopathic Abdominal Exam (Cannon)
I.
II.
III.
“NEED TO KNOW” slide at end says to focus on THESE THINGS
a. All 4 parts of abdominal exam – inspection, auscultation, palpation, percussion
b. Light and deep palpation
c. Involuntary/voluntary guarding
d. Rebound tenderness
e. OMM assessment of the sympathetic, parasympathetic, lymphatic and structural components
f. Special tests – Markle’s, McBurney’s, Murphy’s, Rosvings, Obturators, Psoas, Lloyds
g. Importance of rectal exam (defer in SP)
Abdominal Structures by quadrants
a. RUQ – liver, GB, pylorus, duodenum, pancreas head, r.adrenal, r kidney upper pole, end of ascending
colon, beg of transverse colon
b. LUQ – liver left lobe, spleen, stomach, pancreas body, l. adrenal, l. kidney upper pole, end of transverse
and beg of descending colon
c. RLQ – r. kidney lower pole, cecum, appendix, beg of ascending colon, r. ureter, r. ovary, r. fallopian tube,
r. spermatic cord, uterus if enlarged, bladder if enlarged
d. LLQ - l. kidney lower pole, sigmoid colon, end of descending colon, l. ureter, l. ovary,, l. fallopian tube, l.
spermatic cord, uterus if enlarged, bladder if enlarged
e. *** kidneys, duodenum, and pancreas are posterior and cannot generally be palpated in adults, in
children you may be able to palpate renal masses ***
Sx of Abd Dz
a. Pain – mucosal irritation, smooth muscle spasm, peritoneal irritation, direct nerve stimulation
i. OLD CARTS
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IV.
V.
b. Nausea & Vomiting
c. Rectal bleeding
d. Abdominal distention
e. Change in bowel movements- constipation, diarrhea
f. Early satiety
g. Jaundice
Take Hx
a. OLDCARTS
b. If a woman, “When was your last period?
i. When to get a prego test on a woman w/ abd pain?
c. Referred pain - pain originates in areas supplied by somatic nerves entering the spinal cord at the same
segment as the sensory nerves from the organ responsible for the pain
i.
Osteopathic Abdominal Exam
a. Inspection
i. What to look for
1. General appearance- writhing(renal or biliary colic), perfectly still (peritonitis), pale and
sweating (shock)
2. Respirations – increased with peritonitis, bleeding , obstruction
3. Skin- observe for jaundice, angiomas, nevi, texture, masses, hernias; telangectasias seen
with Osler-Weber-Rendu syndrome; panniculitis from pancreatitis.
4. Hands/ nail beds; large lunula with cirrhosis
Face – melanin deposits in and around oral cavity Peutz-Jeghers syndrome
5. abdomen - look at contour, protuberance may be a sign of: organomegaly, gaseous
distention, ascites, or obesity
a. Describe any asymmetry , distention, masses, peristaltic waves, striae. Silver
striae associated with weight loss and purple striae with adrenocortical excess.
b. Look for ecchymosis, Grey Turner’s sign – is massive ecchymosis noted on the
flanks from pancreatitis (to bruising of the flanks.This sign takes 24–48 hours. It
can predict a severe attack of acute pancreatitis, with mortality rising from 10%
to 40%. It is a sign of retroperitoneal hemorrhage ) and Cullen’s sign – a bluish
discoloration of the umbilicus from hemoperitoneum (presence of blood in the
peritoneal cavity. The blood accumulates in the space between the inner lining
of the abdominal wall and the internal abdominal organs.)
c. Look for hernias of umbilical, inguinal femoral origin and at the sites of any
scars. Have the patient cough to increase intra-abdominal pressure.
d. Valsalva is more commonly performed to attempt to palpate a hernia.
ii. Sister Mary Joseph nodule
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1. Sister Mary Joseph nodule or node, also called Sister Mary Joseph sign, refers to a
palpable nodule bulging into the umbilicus as a result of metastasis of a malignant
cancer in the pelvis or abdomen.
2. Gastrointestinal malignancies account for about half of the underlying sources (most
commonly gastric cancer, colonic cancer or pancreatic cancer, mostly of the tail and
body of the pancreas), and men are even more likely to have an underlying cancer of
the gastrointestinal tract.
iii. Telangectasias
iv. Panniculitis
v. Lunula
vi. Melanin deposits
vii. Ranson’s Criteria – predicts mortality in pancreatitis
b. Auscultation
i. Evaluate bowel sounds, listen for 30 seconds to 2 min.
ii. Normal bowel sounds are every 5-10 seconds and are high pitched, if no sounds after 2 min
“absent bowel sounds” may be from ileus
iii. Low pitched rumbling sounds of gas moving through the intestines are known as borborygmi.
iv. Listen to each quadrant- bruits may signify renal artery stenosis.
c. Percussion
i. Determine the presence of gas, fluid or mass
ii. Liver, start mid-clavicular and go downward; over the liver is dull and over colon more tympanic;
avg. length of liver @ 10cm
iii. Spleen; in posterolateral wall of abdominal cavity hidden by rib cage (Traube’s space ; 6th rib
superiorly, axillary line laterally, and costal margin inferiorly) dullness in this space may be a sign
of splenic enlargement
iv. Ascites – identify area of tympany (gas) and dullness (ascites); have pt. change position and
dullness will shift to dependent position (Shifting Dullness)
v. Ascites – indentified by fluid wave. Pt’s hand indents subcutaneous adipose tissue to prevent
impulse transmission; examiner taps one flank while palpating the other . Detection of a fluid
wave indicates ascites . May see false positive in obese pt’s.
vi. May see bulging flanks if enough fluid is present to push flanks outward
d. Palpation
i. Chapman’s points
1. Appendicitis – tip of rib 12 on R
2. Gallbladder – 6-7 rib on R
3. Diverticulitis – down IT band on L leg
4. Intestines – LLQ is on higher IT band, LUQ is lower on IT band
ii. Viserceosomatic reflexes are parasympathetic or sympathetic
1. Parasymp
a. Two divisions to gastrointestinal tract- increase secretions and motility in GI
tract, as well as relaxes sphincters.
b. Vagus nerve is the main nerve involved, down through the splenic flexure of the
colon.
i. Assess at OA, AA, C2
c. Sacral nerves S2-4 supply the descending colon and pelvic organs
i. Assess at Sacrum or Sacroiliac joints
d. Ganglions are at or near the target organ
e. All viscera from pharynx down to splenic flexure are provided for by vagus nerve
(CN X)
14
f.
i. Associated with OA, AA, C2 and temporal bone restrictions
From descending colon on down, provided for by sacral plexus (S2-4) Pelvic
Splanchnic nerve
i. Associated with sacral dysfunctions
2. Sympa
a. Autonomic innervations
b. Celiac ganglion – innervates the Upper GI tract
i. Receives fibers from T5-9
ii. Feeds:
1. Distal esophagus
2. Stomach
3. Proximal duodenum
4. Liver
5. Gallbladder
6. Spleen
7. Portions of the pancreas
iii. Location: mid epigastric below xyphoid process
c. Superior mesenteric ganglion – Innervates the Middle GI tract
i. Receives fibers from T10-11
ii. Feeds:
1. Distal duodenum
2. Portions of pancreas
3. Jejunum
4. Ileum
5. Ascending colon
6. Proximal 2/3rds of the transverse colon
iii. Location: Midline along Linea alba. Above umbilicus
d. Inferior mesenteric ganglion – Innervates the Lower GI tract
i. Receives fibers from T12-L2, via the 3 lumbar splanchnic nerves
ii. Feeds:
1. Distal 1/3rd of the transverse colon
2. Descending colon
3. Sigmoid colon
4. Rectum
iii. Location: Midline along linea alba. Above umbilicus but below superior
mesenteric
iii. Light palpation
1. to help identify muscle spasm and tenderness. Use the flat part of hand or finger pads,
not finger tips. Lift hand do not slide.
2. Rigidity is involuntary spasm of abdominal wall (does not relax with expiration) and
indicates diffuse or localized peritoneal irritation.
iv. Deep palpation
1. Used to estimate organ size and detect masses, bottom hand flat with upper hand
exerting force with finger tips. May wish to have pt flex knees to relax muscles.
2. Guarding – any voluntary or involuntary muscle spasm (cold hands)
3. Rebound tenderness (referred)– peritoneal irritation caused by palpating deeply and
slowly in an area away from the suspected area of inflammation, the palpating hand is
quickly removed and a sensation of pain is felt at the area of inflammation.
v. Liver palpation
15
1. Hooking – place both hands at area of dullness , lift inward and upward while pt.
inhales.
2. Liver tap – place left hand in RUQ and hit with fist of R. hand. Pain may be felt with
inflammatory processes of liver and GB.
3. Rovsing’s Sign ; pain produced in RLQ when palpating the LLQ
4. Murphy’s sign – pain elicited while palpating gall bladder during inspiration.
5. McBurney’s Point- pain produced at a point 1/3 the distance from the ASIS and 2/3 the
distance from the umbilicus
vi. Spleen Palpation
1. Stand on R. side of pt. and with L. hand elevate rib cage while pushing upward and
inward with R. hand (inspiration) toward anterior-axillary line. An enlarged spleen may
be palpated with finger tips of R. hand.
2. May also try with pt in RLR position with aid of gravity. Similar hand position.
3. Spleen enlarges in diagonal manner toward umbilicus, this is starting position moving
toward LUQ.
4. Splenomegaly: seen with infection, hyperplasia, congestion and neoplasia.
5. Spleen is not palpated under normal conditions
vii. Kidney Palpation
1. Kidneys not normally palpated but may be in children.
2. Palpation of R. kidney. Stand on R. side of pt. L. hand underneath between costal margin
and iliac crest. R hand anterior just below costal margin with finger tips pointing lateral.
3. For left kidney same procedure on L side of pt with R hand underneath
4. Occasional may feel inferior pole of R kidney
5. Costovertebral (CVA or Lloyd’s) tenderness
a. Use fist to gently hit area on both sides of CVA, pt usually seated. Pain elicited
in pyelonephritis
viii. AORTA
1. A periumbilical or upper abdominal mass with expansile pulsations that is 3 cm or more
wide suggests an AAA. Sensitivity of palpation increases as AAAs enlarge: for widths of
3.0-3.9 cm, 29%; 4.0-4.9 cm, 50%; ≥5.0 cm, 76%.41
2. Screening by palpation followed by ultrasound decreases mortality, especially in male
smokers 65 years or older. Pain may signal rupture. Rupture is 15 times more likely in
AAAs >4 cm than in smaller aneurysms.41
e. Rectal exam
i. may be done with pt in standing bent , LLR, or supine positions.
ii. Pt is asked to relax at first and then strain to examine for hemorrhoids.
1. Use one hand to hold buttocks and with gloved and the other hand, that is lubricated, to
place a finger in anal canal. Allow sphincter to relax and place index finger in entire
length. Examine the entire circumference.
iii. DRE – The anterior rectum has peritoneal attachment and may elicit pain with inflammation of
peritoneum.
f. Prostate exam
1. prostate is bilobed, heart shaped, and the consistency of a hard rubber ball. It is about
4cm in diameter and felt during the examination of the anterior rectum. Note any
irregularities and nodules. Palpation is of the posterior portion of the gland.
2. BPH may be felt as a symmetrical enlargement while prostatitis may feel boggy and
tender.
g. Special techniques
16
IV.
1. Psoas sign - Pt lies on unaffected side and extends the other leg against examiner’s
hand. A positive test is pain with this maneuver (intra-abdominal irritation)
2. Obturator sign – pt is supine and examiner flexes the patient’s leg at the hip with the
knee bent and rotates the leg internally at the hip. Pain is felt if there is inflammation
adjacent to the muscle
h. **Incorporate Osteopathic Structural Exam During ALL Phases of Your Exam**
i. examine the area of pain LAST,
ii. pt should be supine, Examiner should be able to walk around the table( not against wall)
iii. abdomen should be fully exposed
iv. arms at sides and legs flat
v. Pillow under knees maybe used to aid relaxation
Other
a. Consider inguinal/rectal examination in males.
b. Consider pelvic/rectal examination in females.
c. Disorders in the chest will often manifest with abdominal symptoms. It is always wise to examine the
chest when evaluating an abdominal complaint.
d. It is always wise to auscultate the heart and lungs.
i. Ask: Sexual Activity, Contraception, Last Menstrual Period, Always Consider Pregnancy in
Reproductive Age Women.
Lecture 5: DDx Abdominal Pain (Cannon)
I.
RUQ Conditions
a. Hepatitis
i. Presents with RUQ pain and/or tenderness
ii. Jaundice is most likely present
iii. Fever is present
iv. Bilirubin level is high
v. Liver enzymes are elevated
vi. History of travel to foreign country
vii. Consuming raw foods
viii. Sexual exposure
ix. Blood exposure
x. Perform what type of study to rule out other causes of pain? US!
xi.
17
II.
b. Cholecystitis
i. RUQ pain and tenderness
ii. (+) Murphy’s sign (inspiratory arrest during palpation) (hook in under liver)
iii. Did patient have a fatty meal?
iv. Is pain worsening after eating?
v. Epigastric pain ?
vi. Perform what type of test to detect gallstones, a thickened gallbladder, or pericholecystic
fluid? US!
c. Choledocolithiasis
i. RUQ pain that is worsened with the ingestion of fatty foods
ii. Presence of at least one gall stone in the common bile duct
iii. Jaundice is often present
iv. Perform an ultrasound to detect dilatation of the common bile duct
v. Best test/procedure= ERCP
vi. ERCP- Endoscopic retrograde cholangiopancreatography (ERCP) is able to diagnose and treat.
1. a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat
problems of the biliary systems. Through the endoscope, the physician can see the
inside of the upper GI tract and inject dyes into the ducts in the biliary tree and pancreas
so they can be seen on X-rays.
d. Biliary Cholic
i. Constant epigastric and RUQ pain
ii. Perform an ultrasound to detect the presence of gallstones without any other gallbladder
related findings
e. Cholangitis
i. A life-threatening condition
ii. Presence of Charcot’s triad: Fever + Jaundice + RUQ pain
iii. If there is also hypotension (or shock) and mental status changes, this qualifies as what?
1. Riddle’s PenTad
iv. Perform an ultrasound and CT to detect biliary duct dilatation due to gallstone obstruction
v. Confirm diagnosis with ERCP
f. Pneumonia
i. Presence of pleuritic chest pain
ii. Often times fever will be present.
iii. What other findings would you think of that will “fit in your box” to make you suspect
pneumonia?
iv. Perform a CXR, which will show pulmonary infiltrates.
g. Fitz-High-Curtis Syndrome
i. RUQ pain, fever
ii. There is going to be a history of salpingitis
iii. Caused by ascending Chlamydia or gonorrhea-related salpingitis
iv. Perform an ultrasound which will show a normal gallbladder and biliary tree with fluid around
the liver and gallbladder
v. Usually involves inflammation of liver.
h. Salpingitis (pelvic inflammation)
i. primarily involves the fallopian tubes, but is commonly thought of as an infection of ovaries and
uterine lining as well.
ii. There is more discussion of salpingitis later in lecture.
iii. How do you dx F-H-Curtis as opposed to biliary colic?
RLQ Conditions
18
a. Appendicitis
i. Diffuse abdominal pain that localizes to the RLQ at McBurney’s point (2/3 distance from
umbilicus to ASIS)
ii. Fever and elevated WBC’s often present
iii. Abdominal xray or preferably CT scan to solidify diagnosis
iv. Decision to remove is based on clinical presentation
v. Consider Markle’s sign.
b. Ectopic Pregnancy
i. Presents with constant lower abdominal pain, crampy in nature
ii. Vaginal bleeding may be present.
iii. Tender adnexal mass (exam = push on abdomen bimanual (one hand in vag area, other on top
pressing down – squeeze area together and elicit pain)
iv. Labs will show beta-hCG
v. Why get beta-hCG? Serum HCG rising (doubling) every 48 hrs = ectopic preg requiring SURGX. If
it stays the same, can give methotrexate and watch and wait.
c. Salpingitis
i. Lower abdominal pain
ii. Purulent vaginal discharge
iii. Cervical motion tenderness
iv. Perform an ultrasound to detect the abscess, and a CT to rule out other conditions.
v. Pelvic inflammatory disease (PID) occurs when bacteria move from the vagina or cervix into the
uterus, fallopian tubes, ovaries, or pelvis.
vi. Most cases of PID are due to the bacteria that cause chlamydia and gonorrhea.
vii. These are sexually transmitted diseases (STDs). The most common way a woman develops PID is
by having unprotected sex with someone who has a sexually transmitted infection.
d. Meckel Diverticulum
i. In distal ileum; presents w/ GI bleed, small bowel obstruction (SBO)
ii. Detecting Meckel’s diverticulum can be difficult.
iii. Ultrasound will commonly miss it.
iv. CT scan is more specific but not definitive.
v. Technetium-99m pertechnetate scan (also called a Meckel scan) is most accurate. Physician
must be highly suspicious of Meckel’s to perform study.
vi. Rules of 2’s
1. 2% of population
2. 2 feet from ileocecal valve
3. 2 inches in length
4. 2 types of ? tissue (gastric and pancreatic)
5. 2 years is most common age at presentation
6. 2 times more common in boys
vii. Meckel’s scan
1. radioactive isotope injected into the bloodstream will accumulate at sites of bleeding, in
stomach tissue or pancreatic tissue. If a piece of stomach/pancreatic tissue or a pool of
blood shows up in the lower intestine, Meckel's diverticulum is indicated.
e. Ovarian torsion
i. Patient develops an acute onset of severe, unilateral pain
ii. Pain changes with movement
iii. Presence of tender adnexal mass
iv. Ultrasound is done first
v. Confirm with a laparoscopy
19
f.
III.
IV.
Pyelonephritis
i. Presents: Patient develops an acute onset of severe, unilateral pain
ii. Pain changes with movement
iii. Presence of tender adnexal mass
iv. Ultrasound is done first
v. Confirm with a laparoscopy
g. Mesenteric Lymphadenitis
i. Lower abdominal pain
ii. Tender to palpation, positive rebound tenderness.
iii. How do you determine between appendicitis or other etiologies?
1. Study says: It is not possible to accurately distinguish acute mesenteric lymphadenitis
from acute appendicitis in children using clinical evaluation alone. Ultrasound or CT
should be performed in equivocal cases.
h. Intussusception
i. most commonly in infants between 5 and 10 months of age
ii. Presence of currant jelly stool (mix of blood and mucus)
iii. Vomiting, intense crying
iv. Air enema is performed first
v. Barium enema is used for diagnosis and treatment
vi. Perform CT scan if needed
vii. Board question: Rotavirus vaccine in peds waiting AFTER 8-16 weeks puts them at great risk
for intussusception
LUQ Conditions
a. MI
i. Crushing chest pain that radiates to the jaw, neck, left arm
ii. Nausea, diaphoresis is present
iii. Diagnosed by EKG, cardiac enzymes, (CKMB, trop I)
b. Peptic Ulcer
i. Presents as epigastric pain that is relieved by foods and/or antacids
ii. Pt presents 6 wk hx of chest pain, is anxious, normal EKG – do a stress test
iii. Perforations presents with acute and severe epigastric pain, may radiate to shoulders
iv. Diagnose with an upper GI endoscopy
c. Ruptured Spleen
i. Usually a history of trauma
ii. Presence of Kehr’s sign (LUQ pain that radiates to the left shoulder)
iii. What nerve is involved? phrenic
iv. Diagnose with an abdominal CT
LLQ Conditions – similar to RLQ (Ovarian torsion, ectopic pregnancy, pyelonephritis, and salpingitis)
a. Diverticulitis
i. Patient has LLQ pain, fever, and urinary urgency
ii. Diagnose with a CT scan, which shows thickening of the large intestine wall
iii. Elevated WBC count
b. Sigmoid Volvulus
i. Most commonly seen in an older patient
ii. Presents with constipation, distended abdomen, and abdominal pain
iii. Contrast enema to diagnose, will see the classic “bird’s beak”
c. Pyelonephritis
i. Classically presents with CVA tenderness, high fever, and shaking chills
20
ii. Positive Lloyd’s sign (pain in the loin on deep percussion over the kidney, even when pressure
causes no pain)
V.
VI.
iii. Elevated wbc cell count
DDx Midline Conditions
a. GERD
i. Epigastric/substernal burning pain
ii. Degree of pain changes with different positions (worse when patient is supine)
1. Why is that? They’re laying down…gastric contents on horizontal plane
iii. Diagnosis made with either a barium swallow, pH testing, or upper GI endoscopy
b. Small Bowel Obstruction
i. Crampy, intermittent pain, Lack of desire to eat., N/V, Diarrhea- early finding
ii. High-pitched bowel sounds initially followed by absence of bowel sounds.
iii. Leading cause of SBO in industrialized countries is postoperative adhesions (60%), followed by
malignancy, Crohn’s disease, and hernias.
c. AAA
i. Asymptomatic usually until it ruptures
ii. If rupture occurs, patient experiences abdominal pain + shock
iii. There is usually a palpable pulsatile periumbilical mass
iv. Ultrasound done first (least invasive), but can visualize with an xray or CT of the abdomen
d. Pancreatitis
i. Epigastric pain that radiates to the back
ii. Nausea is usually present
iii. Vomiting is very common
iv. Most patients aren’t able to tolerate food.
v. Common causes? Alcoholism or gallstones, scorpion bites, hyperTG or hyper-lipid
vi. Treatment?
vii. Ranson’s criteria! Age over 55, WBC greater 16K, glucose greater than 200, AST greater than
250, LDH greater than 350 for initial onset. 48 hr later look for hematocrit to drop by 10%, BUN
inc by 5, PCO2 less than 60%, Ca less than 8, fluid dispersion 6L. 0-2 signs = 2-5% risk of death, 34 15% 40%, all 100%
e. Pancreatic Pseudocyst
i. result of pancreatitis
ii. Consider this if patient had pancreatitis that recurred and/or did not resolve
iii. Ultrasound will show a pseudocyst
Cases at the end
a. Case 1: Patient female. 72 years of age. Presenting on a Friday afternoon in your office. Dull, aching
abdominal pain that has been going on for 5 days. Fever 100 degrees F. States “I feel that I have a really
bad UTI”
i. Questions: how long? Constant/intermittent? Alleve/aggrevative?
ii. Exam findings: tender in pelvis. Positive mcburney
iii. Labs: urinalysis no blood, leukocytes, or nitrites.
iv. Ddx: appendicitis
b. Case 2: 46 yo. Onset of pain rather sudden. States “didn’t feel really well yesterday but this morning is
having intense pain.” she hasn’t been feeling like eating. Describes no bowel movements. States she
doesn’t remember passing any flatus. Hx of Chrons. Family history of colon cancer. No bloody stools
i. Questions: fam Hx
ii. Exam findings:
iii. Labs: CBC. CMP, wbc, plain film.
iv. Ddx: small bowel obstruction
21
Lecture 5: Indirect for C-Spine (Williams)
I.
II.
III.
IV.
V.
Somatic Dyxfxn = Impaired or altered function of related components of the somatic system: skeletal,
arthrodial, and myofascial structures, and related vascular, lymphatic and neural elements.
Those color charts w/ barriers
a. Restrictive barrier:
b. A functional limit within the anatomic ranges of motion, which abnormally diminishes the normal
physiologic range.
i. In other words--within the range permitted by the physiologic barriers
ii. Generally not preceded by the normal joint end feel.
iii. Remember the firmer end feel, less elastic at the end of motion
c. MIDLINE IS IN THE MIDDLE OF THE RANGE OF PHYSIOLOGIC MOTION
d.
MIDLINE = MIDRANGE
e. In indirect method, Move the dysfunctional component away from the restrictive barrier in one or more
planes
Indirect
a. A manipulative technique where the restrictive barrier is disengaged
b. The dysfunctional body part is moved away from the restrictive barrier until tissue tension is equal in
one or all planes and directions
c. Adjust tone through:
i. Gamma efferent chain
ii. Nociceptive input
iii. ANS modification
d. Changes occur in all systems
i. Muscular
ii. Visceral
iii. Neuro & neuroendocrine
iv. Vascular
v. Lymphatic
vi. Metabolic
4 osteopathic principles
a. The person is a unit of body, mind, and spirit
b. The body is capable of self-regulation, self-healing, and health maintenance
c. Structure and function are reciprocally interrelated
d. Rational treatment is based upon an understanding of these principles
e.
Jones Strain/Counter Strain
a. An indirect technique in which the tissue being treated is positioned at a point of balance, or ease, away
from the restrictive barrier
b. To treat the strain, the physician counters the strain by reintroducing the original strain, which is the
position of ease
c. Counterstrain is based on identifying tender points and positioning the patient to eliminate the
tenderness.
d. Explained
i. An event produces a rapid lengthening of a muscle
ii. Afferent feedback indicates possible myofascial damage from a strain
1. Initial “strain” of agonist mm
2. “Panic” lengthening of antagonistic mm
iii. Body attempts to prevent damage by rapidly contracting these tissues (shortening the agonist)
22
VI.
VII.
VIII.
IX.
iv. This lengthens the antagonist
v. Rapid shortening of the agonist and lengthening the antagonist produce an inappropriate reflex
producing a tender point in the antagonist muscle.
e. Jones TPs may be found in muscle belly, tendinous attachments and ligaments
Trigger vs Tender points
a. TRIGGER: Characteristic pain pattern, Located in muscle tissue, Locally tender, Radiating pain pattern,
Taut band of tissue
b. TENDER: No typical pain pattern, Located in muscle, tendon, ligament, Locally tender, No radiating pain
pattern, Taut band not present
JSCS
a. Mechanism of tx involves
i. Most involve alpha Ia afferent and gamma efferent relationships and nociception.
ii. Golgi tendon organs may be involved, bioelectric phenomena, lymphatic and/or interstitial
exchange.
b. Proprioceptive Theory
i. Muscle fibers in hypertonic state due to an inappropriate proprioceptive reflex after an injury.
ii. Injury to agonist  MM spindles stretched  antagonist stretched  antagonist contracts 
Two opposing mm contractions with TP located in the antagonistic mm!
c. Sustained Abnormal Metabolim Theory
i. Tissue Injury alters local body position
ii. Affects local microcirculation & tissue metabolism
iii. Reduces supply of nutrients AND reduces removal of metabolic waste products
iv. Increased inflammation(increase in pro-inflammatory interleukin production)
v. Lowers firing threshold of sensory neurons (localized neuronal sensitization or “facilitation”)
1.
Restores local vascular circulation
2.
Allows for removal of metabolic waste products
3.
Reduces inflammatory mediators
d. Impaired Ligaments-Muscular Reflex Theory
i. Dysfunction results from a “protective reflex” that occurs when ligaments are placed under a
strain
ii. Localized strain in a ligament
iii. Reflexly inhibits mm contraction that would increase this strain in the ligament AND stimulates
mm contractions that reduce the strain
e. Proposed effects of SCS
i. normalize muscle hypertonicity
1. reduce GAMMA gain
ii. normalize facial tension
iii. reduce joint restriction by decreasing muscle tone
iv. increase blood circulation due to reduction of spasm
v. decrease pain- normalize thresholds
vi. increase strength- no joint spasm to work against
Indications for JSCS
a. Presence of a TP.
i. Acute or chronic, may be associated with a viscerosomatic reflex
b. Patient hesitant about other types of OMT.
c. Frail patient.
d. Trial of OMT to access a pt’s tolerance.
CONTRAindications for JSCS
a. RARE!
23
X.
XI.
XII.
XIII.
XIV.
XV.
b. Fracture or torn ligament in the area.
c. Absolute
i. Lack of patient consent and/or cooperation
ii. Inability to tolerate the classic treatment position, meaning that the treatment position must be
modified
iii. Manifestation of neurological symptoms brought on by the treatment position
iv. Exacerbation of potentially life-threatening symptomatology by treatment position (EKG
changes, drop in O2 saturation, etc in a monitored patient)
Dx
a. History
b. Segmental Findings: look for associated TP.
c. Region: scan involved region, then the region above and below.
Tx
a. Find the most significant/relevant TP.
b. Establish a tenderness scale.
c. Monitor TP tenderness and Tissue Texture.
d. Place patient passively in position of comfort.
e. Maintain position for 90 seconds while patient remains passive.
f. Passive slow return to starting point while monitoring TP.
g. Reevaluate tenderness and tissue texture.
JSCS anterior C1 tender point (OA joint TP0
a. High on posterior ascending ramus of mandible
b. Contact TP & rotate away 90º
c. Find it, fold it, hold it, recheck!
Cervical SCS – posterior TPs are on occiput or assoc w/ tip of the spinous processes or lateral to spinous
processes (ie, PC3 TP – eSARA)
a. Indication for Treatment
This procedure is appropriate for somatic dysfunction at C3 to C7
b. Tender Point Location
The tender point lies at PC3 to PC7 posterolateral, at lateral surface of the articular process associated
with the dysfunctional segment (Fig. 9.36).
c. Treatment Position
The physician extends the head and neck to the level of the dysfunctional segment with minimal to
moderate side bending directed at the segment and minimal to moderate rotation away. The physician
fine-tunes.
Facilitated Positional Release (FPR) – indirect myofascial release tx. The component region of the body is
placed into a neutral position, diminishing tissue and joint tension in all planes, and an activating force
(compression or torsion) is added
a. Ex: superficial muscle hypertonicity on RIGHT
i. Patient may need to move back slightly as DO supports head.
ii. Thumb, palm, and middle finger cradle the neck. Middle finger monitors area to be treated.
iii. Gently bend head forward to flatten the cervical lordosis.
iv. Apply axial compression caudally – just enough to be felt at pad of finger. Then bend neck
slightly back and SB toward finger.
v. Hold position for 3 seconds and gently release.
vi. Reevaluate.
Still Technique = specific, nonrepetitive articulatory method that is INDIRECT then DIRECT
a. For AA Joint RL
i. Patient supine.
24
XVI.
XVII.
ii. Hands over parietotemporal regions, with L index finer pad palpates L transverse process of C1.
iii. Rotate head to L to ease barrier. Should be able to feel at finger pad.
iv. Introduce gentle compression through the head directed toward C1.
v. With moderate acceleration, rotate head to the R toward the restrictive barrier.
vi. 6. Reevaluate.
b. For C4 ERRSR
i. Patient supine.
ii. R index finger palpates R C4 articular process.
iii. L hand over patient’s head for control.
iv. Extend head until C4 engaged.
v. RRSR until C4 engaged.
vi. Add compression through the head toward C4.
vii. With moderate acceleration rotate and sidebend the head to the Left, while simultaneously
adding flexion.
viii. Carry to the restrictive barrier.
ix. Reevaluate.
c. For T2 FRLSL
i. Pt supine.
ii. Palpate dysfunctional segment with L index finger pad.
iii. Control head with R hand.
iv. Flex slightly until motion palpated at T2.
v. RLSL the head and neck until motion felt at T2.
vi. Apply gentle compressive force toward T2.
vii. With moderate acceleration, RRSR with a simultaneous gradual extension.
viii. Carry to the restrictive barrier.
ix. Reevaluate.
Ligamentous Articular Strain = goal of treatment is to balance the tension in opposing ligaments where there
is abnormal tension present
a. In other words = DISENGAGE, EXAGGERATE, BALANCE
i. Disengagement: Compress or decompress the joint or fascial plane, increasing pressure or
traction until you are able to move the injured part.
ii. Exaggeration: Carry the injure part back to the original position of injury by: rotating, flexing, or
sidebending or “side-shifting” until a balance point or “Still point”
iii. Balance: Maintain the area of dysfunction in the position of injury (at the balance point) until a
release occurs.
Balanced ligamentous tension
a. All joints in the body are balanced ligamentous articular mechanisms.
b. Ligaments provide proprioceptive information that guides the muscle response for positioning the joint.
c. Ligaments guide the motion of the joints.
d. Explained
i. When a normal joint is at rest in the neutral position muscular, ligamentous and fascial tension
are minimal and they are “balanced.” (balanced ligamentous tension).
ii. As you move away from the neutral point tension gradually increases until you reach the
physiologic barrier.
iii. Between physiologic and anatomic barriers, tension increases more rapidly. As you continue
this motion a “springy” resiliency (“end feel”) is palpated which gets less & less as you approach
the anatomic barrier.
iv. The anatomic barrier is very firm and if challenged will be very painful or traumatic.
25
XVIII.
v. Our treatments are directed toward or away from the restrictive barrier which is PRIOR to the
physiologic barrier. Actually represents lost motion which is within the physiologic or active
range of motion. When you do direct OMT you are NOT moving through the anatomic barrier.
e. Ex: supine, indirect, respiratory force BLT C2-C3 RLSL
f. Ex: fibular hear dysfxn utilizing LAS/BLT
i. Contact fib head with pad of thumb and press inferiorly
ii. Invert foot, balance b/t your 2 hands until a release occurs
Myofascial release = System of dx & tx first described by A.T. Still, which engages the continual palpatory
feedback to achieve release of myofascial tissues.
a. Direct-barrier engaged and tissue is loaded with a constant force until tissue release occurs.
b. Indirect-dysfunctional tissues are guided along the path of least resistance until free movement is
achieved.
c. Example: Thoracic myofascial release
i.
Lecture 6: OMT for GI
I.
II.
Anatomy
a. The region of the trunk below the thoracic diaphragm
i. Consists of two parts
1. Upper part – abdomen proper
2. Lower part – lesser pelvis
ii. These two areas are continuous at the plane of the inlet of the lesser pelvis
1. Inlet is bounded by the sacral promontory, arcuate lines of the innominates, pubic
crests, and upper border of the symphysis pubis.
b. Abdomen proper
i. Superiorly: thoracoabdominal diaphragm
ii. Inferiorly: becomes continuous with the pelvis
iii. Anteriorly: abdominal muscles – rectus abdominis, pyramidales, internal/external obliques and
transversus abdominis
iv. Posteriorly: lower thoracic and the lumbar vertebrae, crura of the diaphragm, psoas and
quadratus lumborum muscles, and posterior parts of the iliac
c. Lesser pelvis
i. Superior and dorsal boundary: sacrum, coccyx, piriformis, and coccygeus muscles
ii. Inferior boundary: levator ani muscles and fascial coverings (pelvic diaphragm)
iii. Anterolateral boundary: hip bones below the arcuate lines and pubic crests and the obturator
internus muscles
Muscular structures
a. Anterolateral
i. Rectus abdominis
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III.
ii. Pyramidalis
iii. External oblique
iv. Internal oblique
v. Transversus abdominis
b. Posterior
i. Quadratus lumborum
ii. Psoas major/minor
iii. Erector spinae
iv. Iliacus
c. Topographic Anatomy
i. Costal Margins
ii. Xiphoid Process
iii. Iliac Crests
iv. Anterior superior iliac spines
v. Pubic crests and tubercles
vi. Inguinal ligaments
vii. Umbilicus
viii. Linea alba
Vascular Structures
a. Abdominal Aorta
i. Celiac
ii. Superior mesenteric
iii. Renal
iv. Inferior mesenteric
b. Veins
i. Small veins and plexuses in the pelvis flow into the external and internal iliac veins
1. Left and right common iliac veins
2. Inferior vena cava
ii. Portal venous system
1. Veins collecting blood from the digestive tract, spleen, pancreas, and gallbladder join to
form the portal vein
a. Carries blood to the liver
b. Hepatic veins convey the blood to the inferior vena cava
c. Lymphatics
i. Thoracic Duct
1. Drains interstitial fluid from the lower extremities, the pelvic and abdominal viscera, the
left arm and the left side of the head
ii. Right Lymphatic Duct
1. Drains interstitial fluids from the upper right section of the trunk, right arm, and right
side of the head/neck
iii. Where do the heart and lungs drain? RIGHT.
d. Visceral structures of the abdomen
i. Stomach
ii. Liver
iii. Gallbladder
iv. Pancreas
v. Spleen
vi. Kidneys
vii. Urinary bladder
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IV.
viii. Small intestine
ix. Colon
x. Aorta and common iliac arteries
1. Why important?
a. Somatic dysfunctions of these muscles/skeletal structures may mimic the pain
of certain abdominal disorders
b. May be painful because of viscerosomatic reflex activity associated with
abdominal problems
Viscerosomatic vs. Somatovisceral Reflexes
a. Viscerosomatic reflex:
i. Characterized by warmth, muscle spasm, tenderness and moisture
ii. Explained by physiologic process of vasodilation, reflex stimulation of alpha motor neurons in
deep back musculature, activation of inflammatory cascade and inflammatory mediators such
as substance P
iii. Numerous studies confirming
iv. Somatic dysfunction that develops in response to visceral pathology -> diagnostic tools! See box:
b. Somatovisceral reflex:
i. Reflex patterns in visceral structures;
produced by stimulating segmentally
related somatic structures
ii. Example: acute low back spasm
causing constipation
c. Percutaneous reflex of Morley
i. A type of somatic pain - directly over
the inflamed organ
ii. Produced by direct contiguous irritation of the parietal peritoneum and the abdominal wall
iii. Responsible for rebound tenderness and abdominal guarding associated with more severe
abdominal pain
d. Neurological Structures
i. Sympathetics
1. Primary sympathetic fibers for innervation of all organs below the diaphragm (except
descending colon and pelvic organs) pass from cells in the thoracic spinal cord *through
the thoracoabdominal diaphragm*
2. They enter the celiac, superior mesenteric and inferior mesenteric collateral ganglia
where they synapse
3. Postganglionic fibers continue on to innervate specific groups of organs in the abdomen
and pelvis
4. Descending colon receives sympathetics from lumbar splanchnic nerves via inferior
mesenteric ganglion; pelvis receives sympathetics from sacral splanchnic nerves which
arise from the sympathetic trunk
ii. Parasympathetics
1. Supplied from the craniosacral outflow
a. Two divisions to gastrointestinal tract
i. Vagus nerve (CN X)
1. Main nerve involved
2. Pharynx down to splenic flexure of the colon
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3. Associated with C2 and temporal bone restrictions (ALWAYS
PICK TEMPORAL BONE ON A BOARDS QUESTION if you don’t
know the answer, apparently)
ii. Sacral nerves S2-4 supply the descending colon and pelvic organs
1. Associated with sacral dysfunctions
V.
AUTONOMIX
a. Sympa
i. Autonomic innervation comes from the splanchnic nerves
1. Celiac ganglion – foregut
a. Receives fibers from T5-9 via the thoracic splanchnic nerves and feeds:
i. Distal esophagus
ii. Stomach
iii. Proximal duodenum
iv. Liver
v. Gallbladder
vi. Spleen
vii. Portions of the pancreas
2. Superior mesenteric ganglion – midgut
a. Receives fibers from T10-11 via the thoracic splanchnic nerves and feeds:
i. Distal duodenum
ii. Portions of pancreas
iii. Jejunum
iv. Ileum
v. Ascending colon
vi. Proximal 2/3rds of the transverse colon
3. Inferior mesenteric ganglion – hindgut
a. receives fibers from T12-L2 via the lumbar splanchnic nerves and feeds:
i. Distal 1/3rd of the transverse colon
ii. Descending colon
iii. Sigmoid colon
iv. Rectum
ii. Splanchnic nerves – situated on each side of body and formed by union of branches from T5-L1.
Greater, Lesser and Least. The superior splanchnic ends in the celiac ganglion = greater
splanchnic nerve, etc.
iii. Look for
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1. TART changes
a. Paraspinal & spinal somatic dysfunction –> viscerosomatic reflexes
2. Chapman’s Reflexes -Anterior and Posterior
3. Abdominal collateral ganglia
VI.
Considerations
a. SYMPATHETICS
i. Increased Tone
1. Slows digestion
2. Slows peristalsis
3. Decreases enzyme release
4. Vasoconstriction
ii. Decreased Tone
1. Reverse of above
2. May increase congestion of liver
b. PARASYMPATHETICS
i. Increased Tone
1. Increases digestion
2. Increases peristalsis
3. Increases enzyme release
4. Vasodilation
ii. Decreased Tone
1. Slows digestion
c. Lymphatics
i. Horizontal Diaphragms
1. Thoracic Inlet
2. Abdominal (Thoracolumbar)
a. REMEMBER, primary sympathetic fibers for innervation of all organs below the
diaphragm (except descending colon and pelvic organs) pass through
3. Pelvic
ii. Abdominal Mesenteries
1. Ascending, Transverse, Descending, Sigmoid, Diagonal
d. Chapman’s Reflex points
i. What = A system of reflex points that present as predictable anterior and posterior fascial tissue
texture abnormalities (plaque-like changes or stringiness of the involved tissues) assumed to be
reflections of visceral dysfunction or pathology
1. Reflexes are located deep to the skin and subcutaneous tissue and most often lying on
the deep fascia or periosteum
2. Vary in size from pea to size of an almond
3. For a CR point to be positive, both anterior and posterior points should be present
4. Use the anterior points initially for diagnostic purposes as they are more widespread
and then confirm by finding the posterior CR
5. Vary in tenderness from mild to almost unbearable
6. Classic treatment is rotary stimulation for 20 to 60 seconds
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ii. GI ANTERIOR
iii. GI POSTERIOR
Iv. Chapman’s point of colon
1. Note the colon is flipped DOWN
iv. Summary
1. GI system may be effected by several mechanisms
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2. Primary organ disease will cause viscerosomatic reflexes resulting in somatic
dysfunction
3. Somatic dysfunction will produce somatovisceral reflexes influencing organ irritation
and dysfunction
4. **Treatment of the primary organ problem will not always resolve the somatic
dysfunction and so both should be treated
5. May also have viscerovisceral dysfunctions, in which case both organs should be
addressed
V.
VI.
VII.
Tx GOALS
a. Address asymmetries, motion restrictions and tissue texture abnormalities that are viscerosomatic
reflections of homeostatic disturbances
b. Decrease or eliminate pain
c. Remove segmental motion restrictions
d. Improve altered skeletal vertebral unit and myofascial motion arising from aberrant visceral and
autonomic activity
e. Decrease or eliminate segmental facilitation
f. Decrease or eliminate trigger point and tender point activity
g. Decrease pathophysiologic musculoskeletal and neuroreflexive factors influencing circulation
h. Enhancing musculoskeletal and neuroreflexive-mediated circulatory functions
i. Improve organ function
j. Alter any or all of the previously mentioned situations as either contributing to, or predictive of, future
health problems
Tx
a. General
i. Treatment of the autonomic system is aimed at the level corresponding to the innervation of
the facilitated segment
ii. The primary and secondary areas should be treated (e.g. gastric ulcer with medication and vagus
nerve to treat excess acid secretion)
iii. Sympathetic and parasympathetic levels will correspond with the organ involved
b. Approaches to using OMT on the ABDOMEN
i. Spinal Approach
1. Should be treated in order to improve spinal motion and ultimately restore normal
nerve function in segmentally related areas
2. Numerous manipulative methods can be used
ii. Peripheral Approach - Goal of techniques are to improve the ability to move fluids throughout
the abdominal region, thus improving the delivery of oxygen, nutrients, and arterial blood to
affected areas, and facilitating venous and lymphatic drainage for the removal of the waste
products of cellular metabolism
1. Thoracic/pedal lymphatic pump
2. Diaphragmatic redoming
3. Thoracic inlet and pelvic diaphragm releases
4. Chapman reflex treatments
iii. Direct Approach
1. Applied directly to the abdomen to alleviate TART changes in the abdominal wall
structures
a. Mesenteric Release
b. Collateral Ganglia
Clinical issues – Post-operative complications
a. ATELECTASIS
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i. What
1. Incomplete expansion of the lungs due to alveolar collapse
2. Most frequent pulmonary complication after surgery
3. Natural response of patient after surgery is abdominal wall splinting and shallow
breathing
4. This prevents full diaphragmatic excursion, so alveoli at the lung bases are not
expanded, decreasing oxygen exchange in these areas
ii. Clinical presentation
1. Low O2 saturation
2. Increased respiratory rate
3. Respiratory distress
4. Increased respiratory secretions
5. Decreased mental status
iii. Tx
1. Incentive Spirometer – try to get alveoli to pop open
2. Oxygen for hypoxemia
3. CPAP for increased respiratory effort
4. Mucolytics/suctioning for respiratory secretions
5. Bronchodilators for bronchospasm
6. OMT!
b. ILEUS
i. What = Functional inhibition of propulsive bowel motility
ii. How – thought to be due to 3 pathways
1. Due to visceral sensory afferents in the splanchnic and pelvic nerves that increase
inhibitory sympathetic activity in the GI tract
2. Post-operatively due to an inflammatory response from intestinal manipulation during
surgery that results in muscle dysfunction
3. Inhibitory neurotransmitters such as nitric oxide and substance P slow gut motility
iii. Clinical presentation
1. Abdominal distention
2. Diffuse abdominal pain
3. Nausea and/or vomiting
4. Inability to pass flatus or stool
5. Inability to tolerate PO diet
iv. MUST rule out mechanical small bowel obstruction, as this may require surgical intervention
1. Imaging, such as KUBs or abdominal CT scans, will help differentiate between the two
v. Tx
1. Keep patient NPO (“nil per os” – nothing by mouth)
2. Start IV fluids
3. NG tube placement if persistent vomiting or abdominal distention to decompress the
stomach
4. Limit opioid pain medications due to constipation
5. OMT!
a. Studies dating back to 1965 demonstrate importance and efficacy of OMT in
interrupting inappropriate viscerosomatic-somatovisceral cycles
i. Numerous studies since which have now shown decreased hospital
length of stay
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ii. Most recent showed a decreased LOS (LENGTH OF STAY) from 11.5
days in non-OMT group to 6.1 days in OMT group!!a 5 DAY
DIFFERENCE.
Lecture 7: Indirect T-Spine (Banhsaly)
I.
II.
III.
Anatomy
a. 3 anatomical regions
i. Upper T1-4
ii. Middle T4-8
iii. Lower T8-L1
b. 4 functional divisions – outflow of sympathetics
i. T1-4: head and neck
ii. T1-6: heart and lungs
iii. T5-9: Stomach, duodenum, liver, gall bladder, pancreas, and spleen
iv. T10-11: Remainder of the small intestines, kidneys, ureters, gonads, and right colon
c. Thoracic Spinous Process
i. Increasingly caudad from T1-T9 and back to almost anteroposterior orientation from T10-12
1. Facet orientation determine the motion of the vertebral segments
a. Remember BUM, BUL, BUM
i. Cervical Superior Facets: Backward,Upward,Medial
ii. Thoracic Superior Facets: Backward,Upward,Lateral
iii. Lumbar Superior Facets: Backward,Upward,Medial
Fryette
a. Law I
i. In the neutral position
1. Sidebending precedes rotation
2. Sidebending and rotation occur to the opposite side
3. Typical of group dysfunctions: T1-4 NSRRL
b. Law II
1. In the non-neutral (flexed or extended) position
2. Rotation precedes sidebending
3. Sidebending and rotation occur to the same side
4. Typical of a single vertebral dysfunction: T4 FSRR
Indirect Method
a. General
i. A manipulative technique where the restrictive barrier is disengaged
ii. The dysfunctional body part is moved away from the restrictive barrier until tissue tension is
equal in one or all planes and directions
b. Adjust tone through
i. Gamma efferent chain
ii. Nociceptive input
iii. ANS modification
c. Changes occur in all systems
i. Muscular
ii. Visceral
iii. Neuro & neuroendocrine
iv. Vascular
v. Lymphatic
vi. Metabolic
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IV.
e. Inherent forces
i. Exaggeration
1. the dysfunctional component is carried away from the restrictive barrier and beyond the
range of voluntary motion to a point of palpably increased tension
ii. Respiratory force
1. Practitioner-directed inhalation and/or exhalation by the patient to assist the
manipulative treatment process
iii. Patient cooperation
1. Voluntary movement by the patient (on instruction from the practitioner) to assist in the
palpatory diagnosis and treatment process
JCSC
a. General
i. indirect technique in which the tissue being treated is positioned at a point of balance, or ease,
away from the restrictive barrier
ii. To treat the strain, the physician counters the strain by reintroducing the original strain, which is
the position of ease
iii. based on identifying tender points and positioning the patient to eliminate the tenderness.
b. Know differences
c. Mechanism of Tx/Effects
i. Many postulates as to how it works
1. Most involve α Ia afferent and ɣ efferent relationships and nociception
2. Golgi tendon organs may be involved, bioelectric phenomena, lymphatic and/or
interstitial exchange
ii. Proposed Effects
1. Normalize muscle hypertonicity – reduce ɣ gain
2. Normalize facial tension
3. ↓ joint restriction by decreasing muscle tone
4. ↑ blood circulation due to reduction of spasm
5. ↓ pain – normalize thresholds
6. ↑ strength – no joint spasm to work against
d. Indication for JSCS
i. Presence of a tender point
1. Can be acute or chronic
2. May be associated with a viscerosomatic reflex
ii. Pt may be hesitant about other types of OMT
iii. Frail patient
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iv. Trial of OMT to assess pt’s tolerance
e. CONTRAINDICATIONS – rare
i. Fracture in the area
ii. Torn ligament in the area
f. Tx in JSCS
i. Identify and label tender point as 10/10 or 100%
ii. Passively position the body into tissue laxity (position of comfort) and retest for tenderness
1. Fine tune in all planes of motion until tenderness is minimized to 0/10 or max of 3/10
iii. Hold for 90s, maintain finger contact to monitor tissue texture changes. REDUCE PRESSURE!
iv. SLOWLY and PASSIVELY return the body to neutral
v. Retest for tenderness and tissue texture
g. Tenderpoints
i. anterior
**7-12 are BILATERAL
ii. Posterior (These are important, tx positions are different. She will give us the specific
tenderpoint to treat for the test)
1. Midline *
a. On the inferior tip of the spinous process
2. Posterior * [Inferolateral]
a. Inferior lateral aspect of the spinous process
b. Bilateral
3. Lateral * [Transverse Process]
a. On transvers process
b. Bilateral
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V.
Facilitated Positional Release (FPR)
a. General
i. A system of indirect myofascial release treatment. The component region of the body is placed
into a neutral position, diminishing tissue and joint tension in all planes, and an activating force
(compression or torsion) is added.
b. Indications
i. Back pain
ii. Chest wall pain
c. CONTRAINDICATION = ACUTE FRACTURE
d. Directions (think – FLATTEN THE CURVE, like T spine is a natural kyphosis so EXTEND IT)
i. Identify tension related to restricted motion
ii. Place the joint or region in its neutral position (Flatten the curve)
iii. Add compression or torsion to facilitate tissue laxity
iv. Palpate the tension and move the joint or region into its position of laxity for all planes
v. Hold position for 3-5s until tension release is completed
vi. Slowly return to neutral
vii. Retest for tension or motion
e. Step 1: Superficial Muscle Hypertonicity (seated technique)
i. Find the area of hypertonicity in T-spine and place finger(s) in that area to monitor
ii. Flatten out thoracic kyphosis by extending to monitored area
iii. Instruct patient to sit up straight, push out chest if needed
iv. Apply compression to area, vector of force is aimed straight down parallel to the spine.
v. Side bend down to monitored area while maintaining compression and extension.
vi. Hold for 3-5 seconds then release.
vii. Recheck
f. Step 2: Somatic dysfxn (Extension – seated technique)
i. Physicians monitoring finger is at the posterior transverse process
ii. Pt is instructed to sit up straight until the thoracic kyphosis flattens slightly
iii. If necessary advised pt. to push out chest until backward bending is created up to monitoring
finger
iv. Physician applies compression, vector of force is straight down parallel to the spine
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VI.
VII.
VIII.
v. Maintaining backward bending and compression, sidebend the pt. to increase extension and
add rotation to the sidebending component *
vi. Hold for 3-5 seconds
vii. Recheck
viii. * For flexion dysfunction, flexion of spine is added after the compressive force is applied.
Otherwise the technique is the same as for an extension dysfunction
g. Step 2: Somatic Dysfxn (extension – PRONE technique)
i. Physician places the index finger of his cephalad hand at the posterior transverse process of
dysfunctional segment
1. With pt. prone, mild flattening of the thoracic kyphosis is usually created
2. You can use a pillow if needed
ii. With caudad hand, physician grasps the patient’s shoulder over the acromion process
1. With hand on the superior aspect of the shoulder girdle, pull the shoulder, parallel to
the table and towards patients feet, until force is felt at the monitoring finger.
2. This creates sidebending
iii. Maintaining this force, physician straightens up, thereby pulling the patient’s shoulder backward
off of the table, creating rotation
iv. These combined motions create compression, extension, side-bending, and rotation up to the
monitoring finger
v. Hold for 3-5 seconds
vi. Recheck
Myofascial Release (MFR) – DO SOFT TISSUE THEN MFR BEFORE YOUR OTHER TECHNIQUES
a. Def
i. System of dx & tx first described by A.T. Still, which engages the continual palpatory feedback
to achieve release of myofascial tissues.
1. Direct-barrier engaged and tissue is loaded with a constant force until tissue release
occurs.
2. Indirect-dysfunctional tissues are guided along the path of least resistance until free
movement is achieved
b. Indications
i. Restricted rotation
ii. Back pain
iii. Chest wall pain
iv. Rib restriction
v. Shoulder pain
c. CONTRAINDICATION = ACUTE THORACIC FRACTURE
Balanced Ligamentous Tension (BLT)
a. General
i. All joints in the body are balanced ligamentous articular mechanisms.
ii. Ligaments provide proprioceptive information that guides the muscle response for positioning
the joint.
iii. Ligaments guide the motion of the joints.
b. See directions for lab – “try to find the sweet spot – errything melts and feels right”
Ligamentous Articular Strain (LAS) - manipulative technique in which the goal of treatment is to balance the
tension in opposing ligaments where abnormal tension is present
a. Tx
i. Identify ligament or myofascial tension
ii. Press into or apply traction to the tense area to engage the tissues
iii. Slowly move the part of the body into its position of laxity for all planes
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iv. Maintain the position of laxity using balanced pressure and follow any tissue release until
completed or inherent motion ( cranial rhythmic impulse) is palpated
v. Retest for tension
b. Mostly for ILL or Piriformis. Providing a pressure equal to what’s being produced in the muscle and
balance it, a fine balance (similar to inhibition but in inhibition you use more pressure)