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 Workshop: OMT Update Gautam Desai, DO, FACOFP Richard K. Ogden, Sr. DO, FACOFP Joshua Cox, DO, FACOFP ACOFP FULL DISCLOSURE FOR CME ACTIVITIES
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Name of CME Activity: ACOFP 52nd Annual Convention and Scientific Seminars
Dates and Location of CME Activity: March 12-15, 2015, The Cosmopolitan Las Vegas, Nevada
Workshop: OMT Update Wednesday, March 11, 2015 3:00pm-5:00pm
Student Program: Rapid OMT Techniques for the Family Medicine Office Friday, March 13, 2015 10:30-Noon
Name of Faculty/Moderator: Gautam Desai, DO, FACOFP
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Date:
2/2/15
Gautam Desai, DO, FACOFP
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Deadline: Wednesday, February 4, 2015
SPEAKER CV AND INTRODUCTION
ACOFP 52nd Annual Convention and Scientific Seminars
REVIEW OF OMM
FOR THE PRACTICING
PHYSICIAN
Richard Ogden, DO, FACOFP FAAFP
Gautam J. Desai, DO, FACOFP, CPI
W. Joshua Cox, DO, FACOFP
BASICS
• T: Tissue Texture Changes:
boggy, ropey, etc
• A: Asymmetry
• R: Restriction of Motion
• T: Tenderness
1
BASICS
• Somatic Dysfunction: The naming of a
somatic dysfunction describes the
direction of ease, in all three planes.
• For example: The third Lumbar vertebra
has a posterior transverse process on the
right.
• Therefore the vertebra is right rotated (the
anterior superior surface determines the
direction of rotation)
LUMBAR VERTEBRA RIGHT
ROTATED
POSTERIOR
TRANSVERSE
PROCESS
2
BASICS
• Fryette’s Principles:
• If the posterior transverse process is
MORE posterior in flexion or extension,
then the somatic dysfunction is in neutral.
• In neutral (FRYETTE PRINCIPLE 1) the
rotation and the side bending go in
opposite directions (Type One Neutral
Group Opposite) TONGO
BASICS
• If the posterior transverse process
becomes less posterior in flexion then it is
a flexion somatic dysfunction
• If the posterior transverse process
becomes less posterior in extension then it
is an extension somatic dysfunction.
• These are both Fryette Principle TYPE 2
• Side bending and rotation go in the same
direction in Type 2 somatic dysfunctions
3
Nomenclature of the Somatic
Dysfunction
• In our example:
• Lumbar 3 is right rotated side bent right
and in flexion so it is written L 3 F RrSr.
• If L 3 were in extension it is written
• L 3 E Rr Sr.
• If the right PTP stays the same in all three
positions it is neutral L 3 N RrSl
• Typically Type 1 is a group curve and
Type 2 is a single segment.
Nomenclature of the Somatic
Dysfunction
• In Type 1 treat the apex (the middle
vertebra) of the curve.
• Example: L 3 – 5 N RrSl, the 3rd lumbar
vertebra is in neutral, is rotated right and
side bent left and the vertebra to treat is L
4.
4
BASICS
• If the vertebra is side bent left then left
side bending is the direction of EASE and
it is RESTRICTED TO RIGHT SIDE
BENDING.
• If it is rotated to the right it is restricted to
rotation left.
• If it is flexed (or extended) then it is
restricted to extension (or flexion).
Patient with Sinus Infection
(Sinus Pain)
Thoracic
Duct
5
Thoracic
Duct
Thoracic Duct Release
(Direct)
FLEX THE
SUPRACLAVICULAR
FOSSA FORWARD
6
Thoracic Duct Release
(Direct)
EXTEND THE
SUPRACLAVICULAR
FOSSA
Thoracic Duct Release
(Direct)
SEQUENTIALLY SIDE BEND
THE SUPRACLAVICULAR
FOSSA RIGHT AND LEFT
7
Thoracic Duct Release
(Direct)
SEQUENTIALLY ROTATE
THE SUPRACLAVICULAR
FOSSA TO THE RIGHT
AND THE LEFT.
Thoracic Duct Release
(Direct)
HOLD THE
SUPRACLAVICULAR
FOSSA INTO THE
BARRIER AND WAIT
FOR TISSUE RELEASE
SEQUENTIALLY
ROTATE THE
SUPRACLAVICULAR
FOSSA TO THE RIGHT
AND THE LEFT.
8
Sub-Occipital Release (Direct)
Sub-Occipital Release
9
Arrows indicate
Direction of
Milking
Sinus Treatment
ARROWS INDICATE
DIRECTION OF
MILKING
10
Galbraith Technique “Mandibular
Tug”
ARROWS INDICATE
DIRECTION OF MILKING
Membranous Portion
Eustachian/AuditoryTube
INDICATES DIRECTION
OF MANDIBULAR TUG.
11
TMJ (TMD): Masquerades as
“I’ve got an ear infection.”
• Temporomandibular Joint Dysfunction:
Pain around the jaw joint, pain with
clenching of teeth, sometimes ringing of
the ears (tinnitus) and tenderness with jaw
motion.
• Otoscopic exam is normal.
PRE-AURICULAR
TMJ(TMD) TREATMENT: LYMPH TECHNIQUE
LYMPHATIC
12
TMJ(TMD)
TREATMENT
MUSCLE ENERGY:
RESISTED MOVEMENT
IN THE DIRECTIONS OF
THE ARROWS.
Patient with Cephalgia
OA Joint:
•
major motions = flexion and extension
*minor = SB and rotation
•
occiput rotates and SB to opposite sides
Atlantoaxial joint
•
primary = is rotation
- atlas rotates about the dens
•
almost no SB or flexion/extension
Typical Cervical Segments (C2 thru 7)
• Rotation and SB usually to same side
clinically, SB and rotation to opposite sides @ times
• Modified Type II Mechanics
13
14
Cervical Spine Treatment
Occipitoatlantal Joint
– Suboccipital Release
•
•
•
•
Myofascial Release
Pt supine with Dr sitting facing pt
Cup occiput and give gentle axial traction
Wait for musculature to relax
– Usually done supine, but can do with pt
slouched in chair, or on reclining chair
Review of Muscle Energy
• Form of OMT where pt’s ms. actively used
in specific direction and v specific
counterforce from specific position
• A direct technique (engages restrictive
barrier and then carries dysfunctional
component into restrictive barrier)
15
Review of Physiology
• Postisometric Relaxation
– neuromuscular bundle is in refractory state
immediately after contraction, allowing passive
stretching to occur
• Reciprocal Inhibition
– as one ms is contracting, antagonist is relaxing
(biceps and triceps)
Cervical Muscle Energy Treatment
OA (i.e. OA ERRSBL)
– Pt supine w Dr sitting
– Dr’s R index finger on sulcus and rest of hand
wrapped around side of neck, Dr’s L hand on top of
pt’s head
– Take to barrier: flex, SB R and rotate L
– Have pt gently straighten head vs dr’s resistance for
3-5 s
– During period of relaxation, take further into barrier
(more flexion, SB R, and rotation left)
– Repeat 3 times
16
Cervical Muscle Energy Treatment
Atlantoaxial Joint (AA)
– Fully flex head and neck (to isolate AA joint)
then rotate into barrier (side with least amount
of rotation)
– Ask pt to gently move twds neutral while dr
resists motion for 3-5 seconds
– During relaxation, move further into barrier
then repeat process until no new barriers
reached
Cervical Muscle Energy Treatment
Typical Cervicals (i.e. C3ERRSBR)
– pt supine w dr sitting behind pt
– Dr’s R index finger on PTP (C3 in this case), and rest
of hand wrapped around side of neck, Dr’s L hand on
top of pt’s head
– Take to barrier: flex, SB and rotate left
– Have pt gently straighten head vs dr’s resistance for
3-5 s
– During period of relaxation, take further into barrier
(more flexion, SB left, and rotation left)
– Repeat 3 times
17
Cervical Still’s Technique
Treatment
Typical Cervicals (i.e. C3ERRSBR)
– Pt seated with Dr standing behind pt
– Dr’s right index finger on PTP (C3 in this case), and
rest of hand wrapped around side of neck to support
(and also to use as a fulcrum)
– Dr’s left hand on top of pt’s head
– Take to where dysfunction already is, and
exaggerate: extend, SB and rotate R until feel
relaxation of tissues. This removes strain from
affected segment
Cervical Still’s Technique
Treatment
-cont
• Push down head with L hand (axial compression)
• Move head away from area of dysfunction. Rotate
head to L, while simultaneously SB L, and flexing
c-spine. Take to the barrier, and as moving
through this vector, may feel a release with
monitoring hand at PTP.
• Then release compression, and take pt to neutral
• Retest
18
Patient with Pneumonia, Bronchitis,
Congestive Heart Failure
•
•
•
•
•
Thoracic Duct Technique
Thoracic Pump
Rib Raising
Pedal Pump
Treat Thoracic spine T 1 – 6
(Sympathetics to lungs and heart)
Patient with Pneumonia, Bronchitis,
Congestive Heart Failure
• THORACIC PUMP
PATIENT CROSSES
ARMS ACROSS CHEST FOR
ATTENTION TO GENDER
SENSITIVITY
PATIENT INHALES AGAINST
GENTLE RESISTANCE OF
PHYSICIAN’S HANDS, GENTLE
OSCILLATORY MOVEMENT
AS PATIENT EXHALES. REPEAT
SEVERAL TIMES AND ON LAST
ANTICIPATED INHALATION THE
PHYSICIAN QUICKLY REMOVES
HANDS FROM CHEST AND THE
PATIENT INHALES MORE
FORCIBLY
19
Patient with Pneumonia, Bronchitis,
Congestive Heart Failure
• THORACIC SPINE TREATMENT T 1– T 6
ARROWS INDICATE
DIRECTION OF
PERPENDICULAR STRETCH
MYOFASCIAL RELEASE TO
TREAT THORACIC
SYMPATHETIC
INNERVATION
TO LUNGS AND HEART
Patient with Pneumonia, Bronchitis,
Congestive Heart Failure
RIB RAISING IS BOTH A LYMPHATIC AND
SYMPATHETIC INHIBITORY TECHNIQUE.
ARROWS INDICATE THE
ANTERIOR AND LATERAL
AND CEPHALAD DIRECTION
OF THE FINGERTIPS LIFTING
THE RIBS.
20
RIB RAISING: CAN BE PERFORMED
SUPINE OR SEATED.
ARROWS POINT
TO SYMPATHETIC
GANGLIA
ANTERIOR TO
RIB HEAD
21
ARROWS POINT TO LYMPH
NODES ANTERIOR TO RIB
HEADS.
Patient with Pneumonia, Bronchitis,
Congestive Heart Failure
ARROWS INDICATE THE
CEPHALAD/CAUDAL
OSCILLATORY MOVEMENT
APPROXIMATELY 100
CYCLES PER MINUTE.
22
The Patient With LBP
The Patient With LBP
23
The Patient With LBP
Lumbar Examination
• Pt either prone or
seated
• Anteriorly compress
right transverse process
– Inducing a left rotation
• Then repeat for the L
– Inducing right rotation
• Repeat rotation test with
flexion, then extension,
and compare to neutral
24
Lumbar Examination
• If motion roughly same in both
flexion & extension
– then neutral dysfunction
– follows Type I mechanics
• If motion more restricted in flexion
or extension
– then flexion/extension
dysfunction
– follows Type II mechanics
• Flexion / extension component of
positional diagnosis is the plane in
which restriction lessened (or
moves more freely)
Perpendicular release
– Pt is prone with Dr standing at side of table,
on opposite side of dysfunction.
– Place thumb and thenar eminence on the
paravertebral muscles.
– Keeping elbows locked in extension, push
downward and laterally on paravertebral
muscles.
– Maintain this pressure for 3 seconds,
allowing for release of muscle tension.
25
Long axis distraction of lumbar
musculature
– Pt prone with Dr standing at side of table, on
opposite side of dysfunction.
– DO’s hands placed in crossed pattern on
affected muscles, with 1 hand at superior
aspect and other hand at inferior aspect of
muscles to be treated.
– Gentle pressure maintained, and then a
stretch placed on affected muscles by
distracting your hands apart until maximal
tension develops.
Lumbar Muscle Energy Treatment
i.e. L3ERRSBR)
–
–
–
–
–
–
Pt seated w dr standing behind pt
Dr monitoring PTP with 1 hand
Have pt clasp hands behind head
Take to barrier: flex, SB and rotate left
Pt gently straightens back vs dr’s resistance for 3-5 s
During period of relaxation, take further into barrier
(more flexion, SB left, and rotation left)
– Repeat 3 times
26
Patient With Knee Pain: History Of Inversion Ankle Injury: Posterior
Fibular Head
FIBULAR
HEAD
MOVES
POSTERIOR
DISTAL FIBULA (LATERAL MALLEOLUS)
MOVES ANTERIOR
PLANTAR FLEXION, INVERSION
Injury
Muscle Energy Posterior Fibular
Head
omurtlak.bloguez.com
RESISTED DORSIFLEXION
OF ANKLE CAUSES THE
FIBULAR HEAD TO MOVE
ANTERIOR (EXTENSOR
HALLUCIS LONGUS AND
ANTERIOR TIBIALIS
FIBERS CONTRACTING)
27
28
Counterstrain Steps
1.
2.
3.
4.
5.
6.
7.
Find a significant tenderpoint
Establish a pain scale
Wrap the patient around the tenderpoint
Reduce pain by 70% with small arcs of motion
Hold for 90 seconds
Passively return patient to neutral
Recheck the tenderpoint
Flexion Ankle
Counterstrain
• This is reverse of
extension force.
Tenderpoint is high
in the front of the
ankle in a depression
medial to the big
extensor tendon.
29
Flexion Ankle
Counterstrain-Treatment
• Exert force under
the ball of the
foot. (can be
reinforced by
physician’s chest)
Fine tune with
slight rotation.
(Flexed) Calcaneus (FCALC)
•
•
Anteromedial plantar surface
of the calcaneus
Common TP in plantar
fasciitis
30
Flexed Calcaneus: FCALC
• Place the prone pt’s dorsal foot
on your thigh
• Use your cephalad hand to
induce anterior force on
calcaneus while pressing pt’s
shin against your thigh
• Use te heel of your hand to
press ball of foot toward the
calcaneus while monitoring the
point with index finger
• Combined motion will
plantarflex the foot
MFR of Plantar Fascia
• Place thumbs of both fingers on sole of
pt’s foot
• Move thumbs in superior and lateral
direction, while maintaining steady
pressure
• Continue until you feel tissues relax
31
Ilio-Sacral Somatic Dysfunction
Standing Flexion Test
• Static: PSIS bilaterally should be at same
level-not asymmetrical
• Pt standing, physician at eye level of PSIS
and patient slowly bends forward.
• PSIS that moves farthest / first is positive
side.
Patient with Hip and Sacral Pain:
Standing Flexion Test Determines side of Iliosacral
Somatic Dysfunction
• Static Heights: PSIS bilaterally should be
level. Record which is lower/higher
BEFORE HAVING THE PERSON
FORWARD BEND.
• Indicative of an upslip or downslip (shear)
32
RECORD WHICH
PSIS MOVES
FIRST /
FARTHEST.:
INDICATES SIDE
OF DYSFUNCTION.
SHADED AREA
INDICATES
PLACEMENT OF THUMB
UNDER
THE PSIS
ASIS OR PELVIC
COMPRESSION TEST
ARROWS INDICATE THE
DIRECTION OF ALTERNATING
COMPRESSION TO FIND THE
HARD END FEEL TO VERIFY THE
SIDE OF SOMATIC
DYSFUNCTION
33
ANTERIOR INNOMINATE ROTATION
ANTERIOR ROTATION ILIUM:
ASIS AND MEDIAL MALLEOLUS
LOWER ON THE SIDE OF POSITIVE
STANDING FLEXION TEST.
MUSCLE ENERGY CORRECTION OF ANTERIOR INNOMINATE ROTATION
•
ARROW 1 SHOWS THE DIRECTION OF THE PHYSICIAN’S FORCE AGAINST
THE PATIENT’S ACTIVATING FORCE, WHICH IS SHOWN BY ARROW 2.
AFTER THE PATIENT RELAXES, THE PHYSICIAN CONTINUES TO ENGAGE
NEW BARRIERS UNTIL NO NEW BARRIERS ARE ENCOUNTERED.
PHYSICIAN MAY INSERT UPTURNED HAND ALONG POSTERIOR ISCHIAL
TUBEROSITY TO AUGMENT CORRECTIVE POSTERIOR ROTATION.
2
1
34
POSTERIOR INNOMINATE ROTATION
POSTERIOR ROTATION ILIUM:
ASIS AND MEDIAL MALLEOLUS
HIGHER ON THE SIDE OF POSITIVE
STANDING FLEXION TEST.
Muscle Energy Correction of Posterior
Innominate Somatic Dysfunction.
BLUE ARROW INDICATES
PHYSICIAN FORCE TO
CORRECT DYSFUNCTION
BLACK ARROW INDICATES
THE DIRECTION OF THE
PATIENT’S FORCE AGAINST
THE PHYSICIAN.
35
Muscle Energy Correction of Posterior
Innominate Somatic Dysfunction.
Arrow 1: Physician force
Arrow 2: Patient force
2
1
• Physician resists
patient flexing hip for
3 – 5 seconds, the
patient relaxes and
the physician
engages the new
barrier.
• The cycle is repeated
until no new barriers
are encountered.
INNOMINATE IN-FLARE AND
OUT-FLARE
ASIS
DISTANCES
FROM THE
XIPHOID
ARE
MEASURED
ON SIDE OF POSITIVE STANDING FLEXION
TEST: ASIS NEAR MIDLINE, INFLARE, IF
FARTHER THEN IT IS AN OUTFLARE.
36
Treatment of an Innominate Downslip
(Inferior Shear)
•
www.stockphotopro.com/photo-thumbs-2/stockpho...
The patient is lying with the
affected side up, and the
physician applies a caudal
force against the patient’s ischial
tuberosity during deep
inspiration and as the patient
exhales, the physician engages the
new barrier until no new barrier
Is encountered. The patient is
re-assessed
Treatment of Superior Innominate
Shear (Upslipped Innominate)
Pt and physician
positioned as in
photo
physician Internally
Rotates the hip
and exerts
axial traction to the
barrier. Pt
attempts to
elevate hip for
3 – 5 seconds,
relaxes and the
cycle is repeated
until no new
barriers and the pt
is re-assessed
Black Arrow Indicates
Traction Caudally
www.mhhe.com/.../illustrations/ch25/25-24.jpg
37
Treatment of Innominate Out-Flare
•
img.medscape.com/pi/emed/ckb/sports_medicine/...
Physician force
Patient force
Patient is supine as in
photo. Physician applies
Adducted force and
Patient resists by
Abducting the hip for
3 – 5 seconds,
then relaxes and the
Physician engages the
new barrier. This
continues until no new
barriers are encountered
and the patient is
re-assessed.
Treatment of Innominate In-Flare
•
www.hwbf.org/hwb/conf/alex47/pat1.jpg
1
2
Patient placed in position
noted in photo (Fabere’s
Test position). Patient
attempts to adduct the
left leg ( arrow 2 ) and
the Physician resists
(arrow 1) for 3 – 5 seconds
then the patient relaxes,
and the cycle is repeated
until no new barriers
are encountered
38
Sacro-Iliac Somatic Dysfunction
Diagnosis: Seated Flexion Test
• Patient is seated on the
table, feet supported,
physician is behind the
patient, at eye level to the
PSIS, thumbs contacting
the undersurface of the
PSIS.
• Patient forward flexes
and physician notes the
side that moves first and
farthest.
scoliosis.org
ASIS OR PELVIC
COMPRESSION TEST
ARROWS INDICATE THE
DIRECTION OF ALTERNATING
COMPRESSION TO FIND THE
HARD END FEEL TO VERIFY THE
SIDE OF SOMATIC
DYSFUNCTION
39
Treatment of Ilio-Sacral or Sacro-Iliac
Somatic Dysfunction:
Balanced Ligamentous Tension
• Patient seated on side of table, physician seated
on chair facing patient.
• Physician applies pressure on the patella
through the femur to SI joint testing each side
individually.
• The physician maintains the pressure on the
side of ease while the patient flexes forward &
backward; rotates right & left at the waist; and
side bends right & left. The patient remains in all
of the planes of ease until the physician feels a
release.
• The Sacro-Iliac joint is then re-tested.
Ilio-Tibial Band Somatic Dysfunction
• Diagnosis is made
with patient supine
with knee flexed and
foot flat on table.
• Physician lifts the
patient’s foot and
places it on the table
lateral to the contralateral thigh.
• Pain along the ITB is
pathognomonic.
• Ober’s Test:
• Patient is lying lateral
recumbent, involved
side up and physician
abducts the involved
hip and gently
releases it.
• Inability to smoothly
let leg drop down is a
positive test.
40
Ilio-Tibial Band Somatic Dysfunction:
Myofascial Release
• Patient is supine with knee flexed and foot flat
on table.
• Physician lifts the patient’s foot and places it on
the table lateral to the contra-lateral thigh.
• The physician then strokes proximally from
lateral knee to greater trochanter.
• May also engage the ITB with perpendicular
stretch and wait for tissue creep.
Piriformis Syndrome
• Diagnosis is made by history of nerve pain
in the deep buttock and radiating laterally
down the posterior hip and thigh, stopping
at the knee.
• Also, there is a tender point in the midposterior gluteal area.
41
Piriformis Syndrome:
Still’sTechnique
• Patient is supine, physician standing at the
Ipsilateral side.
• Physician’s cephalic hand monitors in the gluteal
area the piriformis tender point and with the
caudal hand grasps the ankle, flexes the knee
and fully abducts the hip.
• Both of the physician’s hands guide the foot over
the midline FIRST then the knee and then the
ankle is returned to the original side and the
physician internally rotates the hip which is then
held in extension as the knee is fully extended.
PIRIFORMIS
PIRIFORMIS:
EXTERNAL ROTATOR
AND ABDUCTOR OF
THE HIP.
42
UPPER EXTREMITY: ELBOW
POSTERIOR RADIAL HEAD SOMATIC
DYSFUNCTION
• FALL FORWARD ON OUTSTRETCHED
HAND (FOOSH)
• GENERALLY CAUSES THE FOREARM
TO PRONATE AND THE RADIAL HEAD
THEN GLIDES AND STAYS POSTERIOR
UPPER EXTREMITY: ELBOW
ANTERIOR RADIAL HEAD SOMATIC
DYSFUNCTION
• FALL BACKWARD ON OUTSTRETCHED
HAND
• GENERALLY CAUSES THE FOREARM
TO SUPINATE AND THE RADIAL HEAD
THEN GLIDES AND STAYS ANTERIOR
43
SUPINATION:
RADIAL HEAD
GLIDES
ANTERIOR
PRONATION:
RADIAL HEAD
GLIDES
ANTERIOR
POSTERIOR RADIAL HEAD: SUPINATE THE FOREARM
TO THE BARRIER. PATIENT TRIES TO PRONATE AGAINST THE PHYSICIAN.
HOLD 3-5 SECONDS, PATIENT RELAXES, AND PHYSICIAN ENGAGES
THE NEW SUPINATION BARRIER AND THE PROCESS IS REPEATED
UNTIL NO NEW BARRIERS. PRESSURE USING THE PHYSICIAN’S
THUMB ON THE POSTERIOR RADIAL HEAD PUSHING IT ANTERIORLY
AUGMENTS THE TREATMENT.
SUPINATION:
RADIAL HEAD
GLIDES
ANTERIOR
PRONATION:
RADIAL HEAD
GLIDES
ANTERIOR
ANTERIOR RADIAL HEAD: PRONATE THE FOREARM TO
THE BARRIER.
PATIENT TRIES TO SUPINATE AGAINST THE PHYSICIAN. HOLD 3-5
SECONDS, PATIENT RELAXES, AND PHYSICIAN ENGAGES THE NEW
PRONATION BARRIER AND THE PROCESS IS REPEATED UNTIL NO
NEW BARRIERS. PRESSURE USING THE PHYSICIAN’S THUMB ON THE
ANTERIOR RADIAL HEAD PUSHING IT POSTERIORLY AUGMENTS THE
TREATMENT.
44
WRIST SOMATIC DYSFUNCTION
FLEXION
• With wrist flexion
there is dorsal glide of
the carpal bones.
• BLACK ARROW
• INDICATES DORSAL
• CARPAL GLIDE
WRIST SOMATIC DYSFUNCTION:
EXTENSION
•
www.emedx.com/apex/apex_exercise_images/apex
P
U
PURPLE ARROW INDICATES WRIST EXTENSION, DARK ARROW
INDICATES VENTRAL GLIDE.
45
WRIST SOMATIC DYSFUNCTION:
• FLEXION SOMATIC DYSFUNCTION:
PHYSICIAN RESISTS PATIENT’S
ATTEMPT TO FLEX WRIST FOR 3 – 5
SECONDS AND WHEN PATIENT
RELAXES THE PHYSICIAN ENGAGES
THE NEW EXTENSION BARRIER AND
CONTINUES UNTIL NO NEW BARRIERS
ARE ENCOUNTERED.
WRIST SOMATIC DYSFUNCTION:
• EXTENSION SOMATIC DYSFUNCTION:
PHYSICIAN RESISTS PATIENT’S
ATTEMPT TO EXTEND WRIST FOR 3 –
5 SECONDS AND WHEN PATIENT
RELAXES THE PHYSICIAN ENGAGES
THE NEW FLEXION BARRIER AND
CONTINUES UNTIL NO NEW BARRIERS
ARE ENCOUNTERED.
46
WRIST SOMATIC DYSFUNCTION:
Articulatory Technique
• The patient’s wrist is held between both of
the physician’s thenar eminences and the
physician’s fingers are then interlaced and
the patient’s wrist is then moved through a
figure-of-eight pattern with the patient’s
elbow unsupported to allow gentle
distraction of the radiocarpal joint.
• After several cycles the wrist is then reassessed.
Carpal Tunnel Syndrome
• History of hand
paresthesias,
especially the thumb,
index, long, and radial
aspect of the ring
finger. Symptoms
worsen at night and
during pregnancy due
to compression of
median nerve.
• Positive Phalen’s test
• Both wrists maximally
flexed and place
dorsum to dorsum for
one minute.
www.seattlecentral.edu/.../phalens
_test.gif
47
Carpal Tunnel Syndrome
(cont.)
• Tinel’s sign:
drwolgin.co
m/images/c
arpal%20tu
nnel%20tin
els.jpg
Carpal Tunnel Syndrome
Treatment
1: Palmar Carpal Ligament
1
2: Transverse carpal ligament
2
3: Median nerve
3
48
Carpal Tunnel Syndrome
Treatment
Wrist is extended and thumbs are placed
at the location of the short lines, and
compressing force is maintained as the
thumbs sweep out in the directions of the
arrows. This maybe be repeated until
tissue softening is accomplished.
49
Pt with GI Complaints
Constipation, abdominal pain, flatulence
Check iliotibial bands (Chapman’s)
Soft tissue to lumbothoracic and
lumbosacral areas
• Addresses levels of sympathetics
Iliotibial band release
–
–
–
–
Pt supine with affected hip and knee flexed to place
foot on the affected side flat on the table.
Dr standing at side of table facing pt.
DO places one hand on the knee to stabilize.
Other hand placed on lateral aspect of knee and
pressure applied to the depth needed to affect the
dysfunctional tissue
•
–
Use heel of hand, or flat part of hands
Stroke up lateral aspect of thigh to greater
trochanter, maintaining pressure on the IT band.
50
Thoracolumbar Diaphragm
Myofascial Tx
• Pt supine with dr at side of table
• Dr places 1 hand over right ribs 7 -10 and
the other hand contacts the left ribs 7 -10
in the midaxillary line
• Induce SB, noting restrictive barriers
Thoracolumbar Diaphragm
Myofascial Tx
• Induce transverse plane motion (rotation)
noting restrictive barriers
• Apply direct myofascial release technique
to barriers found
• After release of tissues, reassess region in
same manner as above
51
Mesenteric Cecal Lift
• Pt supine with knees bent
• Dr places heel of right hand on caudad
part of RLQ
• Push cecum cephalad
• Listen with hands and await tissue
softening
52
Doming the Diaphragm
• Pt supine with Dr standing, facing pt’s
head
• Dr places hands on pt’s lower ribs, with
thumbs under costal margin
• As pt inhales, exert cephalad force on
diaphragm
• As pt inhales, resist caudad motion with
thumbs
• Continue for 3-4 cycles
53