Download diversified: all moves - Logan Class of December 2011

DIVERSIFIED: ALL MOVES
** I took notes in class and wrote down pretty much everything he said! I have italicized things that he
indicated were unique. I hope this helps for the “untricky” final he keeps talking about!**
*Pelvis and SI*
- Prone:
o Prone A
 Make sure your body is over pt.
o Prone B
 Good for geriatrics
o Modified A
 Lift leg above knee or flex and put leg in front of you
 Pollicus on PSIS or pisiform with fingers directed medial
 Lift leg straight posterior
o Anterior Ilium
 Pisiform on PSIS between S2 tubercle
 Don’t block too lateral, make sure medial to PSIS
- Side Posture: Dr. hips are on top of pt./ line your body up with pt.
o PI Ilium
o Ant Ilium
 Can reinforce hand or support shoulder
o AS Ilium
o Inferior Ilium
 Contact ischial tuberosity with shoulder behind adjusting hand
o Long lever Anterior Ilium
 Pt. has hands interlaced on ribs and is torqued out
 Dr. has both legs behind pt. flexed leg
 Dr. contacts ischial tuberosity with pisiform
 LOD is anterior
o Superior Ilium
 Lateral index in popliteal fossa
 Superior traction (on shoulder) and inferior traction (using leg)
should move as a unit
- Alternative Moves
o Pregnant lady/Obese
 Hold pt. hand from posterior
 Pisiform on PSIS and LOD anterior
o Anterior Ilium – Side posture
 Pisiform contact on ASIS with superior hand and on ischial
tuberosity with inferior hand – counter torque
Sarah Worsfold
Summer 2007
1
*Lumbar Spine*
- Prone: foot piece third notch, abdominal piece unlocked and pelvic piece at
level of greater trochanter
o Recoil
 Turn pt. head towards
 L4-5 use inferior hand, L1-2 use superior hand
 LOD is anterior
o Single Mamillary
 L1-2 superior hand pisiform – hook ASIS with inferior hand
 L4-5 inferior hand pisiform – hook rib cage with inferior hand
(ASIS first)
 Move could be used just to assess ROM and passive mobility
o Retrolisthesis
 Vertebra has gone PI so LOD is AS
 Tissue slack inferior to superior
 Can use knife edge or hand heel on spinolaminar
 Stand behind pt to show LOD
o Bimanual contacts for Rotational Malposition
 Thumb-pollicus
 Thumb medial LOD on spinous
 Pollicus anterior LOD on mamillary
 Pisiform-thumb
 L5 towards the bum
 Double thumb
 L5 face head ward
 Thumb pisiform
 Don’t perform at L5
o Flexion malposition – Bimanual posterior disc
 Use double thumb contact with LOD AI
 Tissue slack superior to inferior
 Spinal contact = open wedge
o Typical disc (dictated by superior vertebra – spinous toward open
wedge)
 Stand on side of open wedge
 LOD
 Disc = AM
 Mamillary = AS
o Atypical disc (dictated by superior vertebra – spinous away from open
wedge)
 Stand on side of open wedge
 LOD
Sarah Worsfold
Summer 2007
2
-
 Disc = AM
 Spinous = MS (bend elbow)
o Open wedge (no typical or atypical rotation)
 Thumb into open wedge with LOD AM
 Pisiform on sacral ala of same side with LOD AS
o Pisiform Leg Lift (for L4-L5 and L5-S1)
 Pisiform on open wedge with LOD AM (can use thumb)
 Lift leg posterior and lateral
Side posture: **Special table position for Accordion and Lateral Listhesis:
abdominal piece unlocked, pelvic piece slid down and foot piece on 3rd notch**
o Accordion (**)
 Open wedge up
 Pisiform/hand heel on sacral ala
 Dr. faces superior with LOD SM
 Dr. holds elbow into body and body drop to close open wedge
o Lateral Listhesis (**)
 Lateral thumb contact on spinolaminar junction with elbow
shrug into body and drop medial
 No rotation involved so see with OA pt
 Misalignment of L/S but very subtle
o Retrolisthesis
 Contact spinous process with thumb web or hand heel
 Tissue slack from inferior to superior with LOD AS
o Lumbar rotation
 Spinous process down and high mamillary up
 Contact with pisiform/pollicus/flat thumb/hand heel
 LOD anterior (elbow shows LOD)
o Pull through
 L4-L5, L5-S1 with open wedge down
 Cup ASIS by rolling pt. forward and then back onto hand
 Traction inferiorly on leg and superiorly on shoulder then shrug
medially on ASIS
-
Supine: foot piece to third notch, pelvic piece at PSIS, abdominal piece
unlocked
o Spondylothisthesis
 Pt. supports themselves on the table
 Give pt legs a quick pull then bend knees
 3 ways to contact pt,
 Dr. arms crossed on flexed thighs and knees
 Dr. chest on knees with B/L PSIS contact
 Dr. shoulder under knees with B/L PSIS contact
Sarah Worsfold
Summer 2007
3
*Cervical Spine*
- Unique Points
o C ½ Counter Rotation ~ only apply to this call
 Supine  hold above or below
 Prone  always hold above
 Seated  always hold occiput
o C1 – Ant: DISH
 Up or down, always supine
o C3-C7 (hold occiput with non-adjusting)
 Luschka (cervical disc)
 Capsule
 Retro (OA pt, whiplash acute pt)
o Occiput
 SIP – supine: inferior, posterior
 PIA – prone: inferior, anterior
 SeALL – seated: all 3
- Supine
o Posterior Occiput
 Side adjusting up
o Inferior Occiput
 Side adjusting down
o Anterior Atlas
 Contact TP of atlas with LOD posterior(up)
 Contact TP of atlas then rotate head and extend with posterior
LOD (down)
o Luschka
 Lateral flexion and superior traction
 LOD medial
o Capsular
 Lateral index contact
 Superior traction, lateral flexion and rotation
 Depict LOD relative to segment adjusting
 Lower: LOD AI
 Middle: LOD Anterior
 Upper: LOD AS
o Counter-rotation
 Hold C1 adjust C2
 Hold C2 adjust C1
o C1
 Hold posterior ring of atlas
Sarah Worsfold
Summer 2007
4
-
Prone
o Inferior occiput
 Turn side adjusting up
 Use ulnar aspect of wrist to adjust
 Ulnar-deviate, traction scapula inferior and LOD is
superior
o Anterior occiput
 Same contact as above
 LOD posterior
o Retrolisthesis
 LOD AS
 2 possible
 Thumb-lateral index
o Lift head, give impulse thrust and hold
 Bimanual recoil
o Head piece up
o Tissue slack inferior to superior and recoil
adjustment
-
o Luschka
 Dr. can stand on same side, opposite side or head of table
 Contact lateral most aspect of vertebra
 LOD medial with lateral flexion on head
o Capsule
 Upper – better from side of table because of LOD
 Middle
 Lower – better from head of table because of LOD
o Counter-rotation
 Hold with flat thumb
Seated
o Inferior occiput
 Dr. stands at 90 on same side adjusting reaching in front of
patient to stabilize opposite side
 Dr. contacts mastoid with LOD superior
o Posterior occiput
o Anterior occiput
 Fingers depict LOD on mastoid
o Luschka
 Lateral index contact on lateral most aspect
 Hold occiput with non-adjusting
o Capsule
 LOD changes so move elbow to depict thrust in plane of capsule
Sarah Worsfold
Summer 2007
5
*Thoracic Spine and Ribs*
Law of 13
1
12
2
11
-----------------------------1½
3
10
4
9
5
8
-----------------------------2
6
7
1
-
Prone: foot piece elevated, pelvic piece at greater trochanter and abdominal
piece unlocked
o Recoil
 Turn head to side adjusting
 Use had opposite from L/S
 Inferior hand for T1-T6
 Superior hand for T7-T12
 Osseous contact in spinolaminar junction
 Bend elbows and recoil
o Bimanual for rotation (Rotational malposition)
o Thumb
 Dr. can stand at head of table, same side or opposite side
 Flat thumb contact on spinolaminar junction and lift occiput
toward side adjusting
o Single transverse
 Pisiform contact on TP with LOD anterior
o Superior transverse (head of table)
 Flat, adducted thumb on TP
 Traction head laterally
 LOD anterior and slightly inferior
 Make sure forearm stays up
o Pisiform crossover
 Cross pisiform on TP and head goes away
 Lock elbow and thrust anterior
o Retrolisthesis (Extension malposition)
 LOD AS
 Tissue slack from inferior to superior
 Osseous contact with hand heel on spinolaminar junction
o Counter rotation (double pisiform)
 Stand on the side of high TP of inferior vertebra
 Pinkies of both hands should face EOP
Sarah Worsfold
Summer 2007
6
 LOD ALS
o Typical disc (same rules as L/S)
 Flat thumb in open wedge  LOD AM
 Pisiform on high TP  LOD AS
o Atypical disc (same rules as L/S)
 Flat thumb in open wedge  LOD AM
 Pisiform on SP  LOD MS
o B/L posterior disc (Flexion malposition)
 Double pollicus contact on spinolaminar junction of superior
vertebra (in L/S double thumb is on disc!!)
 Tissue slack superior to inferior
 LOD anterior thru the disc plane
o Pisiform traction (head of table)
 T1-T4
 Turn head toward side of open wedge
 Traction head and pisiform into open wedge with LOD AM
*make sure elbows are locked for all moves except atypical disc move because of
medial LOD*
-
-
Ribs
o Single manual rib
 Tissue slack is lateral to medial (j-move)
 Contact the rib tubercle – costotransverse joint is part of contact
 LOD AS
o Bimanual rib
 Superior hand blocks spine with pollicus
 LOD AM or AS
Alternative moves
o AP for retro, single rotation or counter-rotation
 Hand in fist
 General, intended for motion, not very specific
Sarah Worsfold
Summer 2007
7
*GH/Shoulder and Elbow*
- Shoulder
o 9 assessments (supine) with adjustment at end of assessment
 Lateral glide
 Hand in axilla
 Anterior glide
 Block clavicle
 10 degree posterior-superior
 Hand on opposite shoulder
 1 finger on humeral head and 1 on acromion
 90 degree posterior
 Hand on opposite shoulder
 1 finger on humeral head and 1 on acromion
 Lateral posterior glide
 Block with superior shoulder
 Kneel at 90
 Lateral inferior glide
 Block with inferior shoulder
 Kneel at 45
 External rotation
 Pt. arm is resting on Dr. knee
 Interlace fingers around humerus and use forearm to
accentuate
 Internal rotation
 Same as described above
 Circumduction
 Pt arm between Dr. knees
 Good assessment for adhesive capsulitis
o Seated adjustment
 Consider impingement syndrome and bicipital tendonitis
 Block scapula and can perform at 10 degrees (posterior-superior)
or 90 degrees (posterior)
- Elbow
o Assessments/Adjustment
 Extension
 Palpate olecranon and extend elbow
 Impulse before lock-out
 Long axis extension
 Block cubital fossa
 Palpate olecranon
 Medial/Lateral Tilt
Sarah Worsfold
Summer 2007
8

 Flex elbow to 10 degrees and challenge
Posterior proximal radial head
 Assessment is Mill’s test while palpating proximal radial
head
 Impulse before lock-out

Superior glide of proximal radius (supine)
 Palpate radial head
 Line up your radius with pt.
*AC, SC, TMJ, 1st Rib, and Scapula*
- Factoids
o AC
 2nd m/c joint for arthritis (#1 = 1st MCP)
 Watch out for impingement issues
 Strengthen rotator cuff muscles to keep humeral head away
o SC
 More rare, seen a lot in weight lifters
 Meniscoid disc within joint
o TMJ
 Internal TMJ too painful, noted by pt.
 Mouth guards may be helpful
 Don’t chew gum all day and don’t eat hard foods
o 1st rib
 Keep in mind with TOS (cervical rib)
 Adjust in conjunction with something
 “Clean the alley” – adjust elbow, 1st rib and spine
o Scapula
 Mobilization secondary to T/S or shoulder problem
 Manipulate and mobilize especially with adhesive capsulitis
- Assessment/Adjustment
o AC
 Assess: One finger on acromion and one on clavicle
 Inferior shear
 Long axis extension (at 90)
 Circumduction (above and below 90)
o Past 120 = AC and scapula joints
 Adjust:
 Seated
o Elbow at 90, block spine, LOD posterior
 Supine
Sarah Worsfold
Summer 2007
9
o Pisiform at 45 degrees with impulse
o Pollicus crossover

ON BOARDS
o Thumb-lateral index in joint and traction superior
on arm and thrust inferior
o SC


Assess: reach around in front of pt and feel, other hand holds
elbow
 Long Axis Extension at 90
 Circumduction at 110
Adjust:
 Seated
o Behind pt with pisiform on joint, pull away from
side and LOD posterior
 Supine
o Pt puts same side hand behind head
o Dr. uses pisiform on joint (B/L) and impulse
o 1st Rib
 Assess:
 Palpate rib with chiropractic index and index
 Rotate head away and extend and laterally flex towards;
“bucket handle” – should feel drop away

o TMJ

Adjust:
 Seated
o Flex palpating fingers and put head into position
described above
o Thrust inferior and medial with elbow up
 Prone (2 ways)
o 1. Same contact as seated and laterally flex head
toward side with LOD inferior and medial
o 2. Turn head away then extend and laterally flex
toward
 Supine
o Pt. slides off table and Dr. rotates head away and
laterally flexes toward
Assess:
 Palpate joint on outside of ear asking pt to slowly open
mouth wide
 Check for side that moves LEAST or LAST = side
adjusted
Sarah Worsfold
Summer 2007
10

Adjust:
 Supine:
o Turn head away
o Ask pt to open mouth slightly and relax jaw
o Stabilize head with forearm and with other hand
contact angle of jaw (pisiform/pollicus) and adjust
thru joint)
o Scapula
 Prone
 Pt arm behind back
 Contact inferior angle of scapula
o Medial/Lateral tilt
o Circumduction
 Side posture
 Same procedure described above
*Hand and Wrist*
- Factoids
o Hand/Wrist
 Carpal tunnel
 Trapezium-1st metacarpal = m/c arthritis in females
 Extensor synovitis
 Ulno-meniscal-triquetral joint
 Lunate luxates
 Scaphoid erosion
- Assessment/Adjustment
o AP/PA intermetacarpals
o AP/PA radiocarpal, intercarpals, distal carpal-metacarpal
 Arms extended
o Rotation carpal-metacarpals
 Figure 8
o Long Axis Extension
 Not specific for one joint
o Extension of the wrist
 Palpate distal row of carpals on proximal row
o Flexion of wrist
 Palpate proximal row of carpals on radius
o Medial/Lateral tilt
 Impulse from test position
 Use two hands
Sarah Worsfold
Summer 2007
11
o Ulno-meniscal-triquetral
 Distract and radial deviation, hook into it
o AP/PA triquetrum
o Trapezium-1st metacarpal
 Assess:
 Stabilize on hip
 Palpate joint by pulling 1st MCP and pushing into joint
 Adjust:
 Reinforced thumb on joint
o Distal radioulnar joint
 AP/PA
 Block a top and shear at bottom
 Rotation
 Pronate and supinate
 Ulna away
*Hip, Knee, Ankle and Foot*
- Factoids
o Hip
 OA of hip common in geriatrics
 AVN of hip
 1 common factor = extreme pain with internal rotation
 Torn labrum
 MRI with contrast should be performed
 Muscle issues
 Soft tissue technique good for muscles here
- Assessment/Adjustment
o Hip
 Extension (prone)
 Assess:
o Block SI and palpate trochanter
o Lift knee and extend hip
 Adjust:
o Pollicus/hand heel on trochanter
o Extend leg and drop with LOD AM
 External rotation (prone)
 Assess:
o Block SI and palpate trochanter, push leg toward
opposite buttock (like Ely’s)
Sarah Worsfold
Summer 2007
12


Adjust:
o Lift leg while in assessment position and thrust
AM
Internal rotation (prone)
 Assess:
o Block SI and palpate trochanter, pull leg away
from body (like Hibb’s)


Adjust:
o Lift leg while in assessment position and thrust
AM
Long Axis Extension (supine)
 Externally rotate to 45 then lift leg by ankle (don’t’ grab
below mortise joint)
 Subtle impulse thrust


Flexion (supine)
 Good to test ROM and tightness of hamstrings
Long Axis Extension (side posture)
 Supinated hand 1 inch distal to trochanter and drop thru
femur
o Knee
 Patellofemoral joint (supine)
 Thumb-web index with both hands
 Assess all ranges of motion
 Femorotibial joint
 AP/PA glide
o Pt knee flexed and hip at 90 with Dr. inferior
thigh under pt knee
o Superior hand palpates tibial condyles
o Adjust with pisiform contact for AP


Internal/External rotation
o Adjust impulse with fingers interlaced
Medial/Lateral tilt
o Adjustment given before full extension
o Pollicus over lateral aspect affects medial side of
joint (vice versa)


Superior glide of Fibula
o Dorsiflex foot to feel fibula glide superiorly
AP/PA glide of Fibula
o Leg flexed to 45 with foot flat on table
o Prone adjustment for PA – see below
Sarah Worsfold
Summer 2007
13

Adjustment
 Tibial adjustment (prone)
o Stand on same side you’re adjusting
o Lateral index in popliteal fossa with superior hand
and inferior hand on distal tibia
o Impulse thrust with inferior hand on tibia –
flexing leg

Fibular adjustment (prone)
o Stand on opposite side you’re adjusting and reach
across to opposite knee
o Same contact as above
o Impulse thrust with superior hand anteriorly with
knee fully flex
o Ankle
 Mortise joint
 AP/PA glide
o Stand on instep side of foot with leg at 45 and toes
off table


Long Axis Extension
o Supine – involves knee and hip
o Prone – take out hip, stabilize pt. thigh with knee
Subtalar – Calcaneal joint
 Medial/Lateral tilt
 Inferior glide (prone)
o Pt knee flexed to 90
o Thumb-index on anterior talus and thumb-index
on posterior calcaneus
o Shear by squeezing hands together

o Foot



Distal fibula AP/PA glide
o Can adjust supine or side posture
Intermetatarsal joints
 AP/PA glide
Metatarsal-tarsal joint
 Rotation
o Cup calcaneus with one hand and thumb-web
contact over proximal metatarsals
o Figure 8
Cuneiform-Metatarsal
 AP/PA (check individually)
o Adjustment
Sarah Worsfold
Summer 2007
14

Dorsal subluxation – dorsiflex and evert
and impulse with inferior LOD

Plantar subluxation (Locke’s maneuver) –
pt standing, double thumb contact over
segment and raise pt foot until level with
opposite knee, impulse foot towards floor
without plantarflexion


Cuneiform/Cuboid – Metatarsal joint (distal row)
 AP/PA
o Stand on instep side of foot to assess
Cuboid
 AP/PA
o Adjustment
 Dorsal subluxation – pushing cuboid
inferiorly

Plantar subluxation – pulling cuboid
superiorly
Sarah Worsfold
Summer 2007
15