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Work Related Somatic Dysfunction Stuart Williams D.O. Associate Professor OMM Dept Sedentary Posture • Leads to exaggeration of normal sagittal plane curves. – Ex: increased lordosis in cervical spine – Ex: increased kyphosis in T spine OA Joint Supine Direct ME – Flexion SD • Pt is supine & DO at head of table • Support lateral masses of atlas between index finger & thumb • Use other hand to grasp pt’s head and induce extension of the occiput to restrictive barrier • Instruct pt to “Nod your chin toward your throat” while DO offers isometric counterforce & localizes to the OA joint • Instruct pt to relax & engage new restrictive barrier • Repeat steps 3-4 times & recheck OA Joint Supine Direct ME – Extension SD • Pt is supine & DO at head of table • Support lateral masses of atlas between index finger & thumb • Use other hand to grasp pt’s head and induce flexion of the occiput to restrictive barrier • Instruct pt to “Raise your chin upward” while DO offers isometric counterforce & localizes to the OA joint • Instruct pt to relax & engage new restrictive barrier • Repeat steps 3-4 times & recheck Seated Cervical Motion Test: • • • • • Can do both actively and passively. A. Forward Bending (sup & inf division) B. Backward Bending (sup & inf division) C. Sidebending D. Rotation (sup & inf division) • Look for: ROM, resistance to motion, unilateral restriction of motion. Cervical Screening and Diagnostic Tests; Cervical Soft Tissue Review David Russo, PRF Department of Osteopathic Manipulative Medicine Modified by Stuart F. Williams D.O. November 6, 2001 • Cervical Spine Range of Motion Rotation – 50% occurs at AA joint, 50% rest of Cspine – Should be able to bring chin to shoulder – approx. 90 degrees each directions Cervical Spine Range of Motion • Flexion/Extension – total range 90 degrees each direction OA Sagital Plane Somatic Dysfunction • Forward Bending (Flexion SD) – condyles have moved posterior in relation to C1 – space between occiput and C1 feels deeper – patient looks like chin is tucked • Backward Bending (Extension SD) – condyles move anterior in relation to C1 – space between occiput and C1 feels shallower – patient looks like chin is sticking out Pinch Technique for Sagittal Plane OA Dysfunction • Examiner sitting at patient’s side • Stabilize tubercle of C1 with thumb and forefinger • Cradle occiput in other hand • Rock occiput forward and back • Appreciate quality of movement Cradle Technique for OA Dx • Hands cradle occiput with fingertips of index and middle fingers over occipital articulation • Test right and left translation (sideslippage) • May also check forward and backward bending • Somatic dysfunction named for the way the segment wants to move – Opposite of the restriction Pinch Technique for Sagittal Plane OA Dysfunction • Examiner sitting at patient’s side • Stabilize tubercle of C1 with thumb and forefinger • Cradle occiput in other hand • Rock occiput forward and back • Appreciate quality of movement Cradle Technique for OA Dx • Hands cradle occiput with fingertips of index and middle fingers over occipital articulation • Test right and left translation (sideslippage) • May also check forward and backward bending • Somatic dysfunction named for the way the segment wants to move – Opposite of the restriction Somatic Dysfunction of the AA Joint • Somatic dysfunctions occur in left and right rotation of the AA joint – Inspection • head may be deviated to left or right – Palpation • Transverse process of atlas may feel posterior (closer to the mastoid process) on side of rotation – Motion testing • Preference for rotation in one direction; limitation in opposite Atlanto-axial Joint • The anatomy of the AA joint dictates its motion • The AA joint moves in rotation only & makes up 50% of cervical rotational motion • There is a little bit of “wobble” but it is CLINICALLY INSIGNIFICANT Somatic Dysfunction of the AA Joint • Motion testing – Forward bend patient’s head to “lock-out” lower vertebrae – Rotate left, rotate right – Somatic dysfunction is named for the way the vertebrae wants to move Functional Anatomy • Atypical vertebrae – Motion named for superior vertebra on inferior vertebra – Atlas (C1) on axis (C2) • Anatomy dictates motion – Primarily rotation, providing 50% total cervical rotation – 45° rotation in either direction – Minor side-slipping, though clinically unimportant Functional Anatomy • Atlas (C1) – No Spinous process – No Body (fell to become dens on Axis) – Lateral masses (transverse process) • Between angle of mandible and mastoid • Transverse foramen hold vertebral artery and sympathetic plexus • Acts as a lever for muscles to rotate head • Axis (C2) – First spinous process – Dens (odontoid process) formed from “body” of Atlas – Lateral masses also hold vertebral artery and sympathetics • AA Joint – No intervertebral disc – Inferior articular facets of atlas are concave – Superior articular facets of axis are convex Atlas (C1) Concave Surfaces Anterior Articulation of Dens Dens (Odontoid Process) Axis (C2) Convex Surfaces Functional Anatomy • Atlas (C1) – No Spinous process – No Body (fell to become dens on Axis) – Lateral masses (transverse process) • Between angle of mandible and mastoid • Transverse foramen hold vertebral artery and sympathetic plexus • Acts as a lever for muscles to rotate head • Axis (C2) – First spinous process – Dens (odontoid process) formed from “body” of Atlas – Lateral masses also hold vertebral artery and sympathetics • AA Joint – No intervertebral disc – Inferior articular facets of atlas are concave – Superior articular facets of axis are convex Functional Anatomy • Atlas (C1) – No Spinous process – No Body (fell to become dens on Axis) – Lateral masses (transverse process) • Between angle of mandible and mastoid • Transverse foramen hold vertebral artery and sympathetic plexus • Acts as a lever for muscles to rotate head • Axis (C2) – First spinous process – Dens (odontoid process) formed from “body” of Atlas – Lateral masses also hold vertebral artery and sympathetics • AA Joint – No intervertebral disc – Inferior articular facets of atlas are concave – Superior articular facets of axis are convex Indications For Treatment • • • • • Restore loss of range of motion Improve function of upper extremity Relieve pain or spasm in neck or UE Relieve cephalgia (headache) Facilitate lymphatic drainage from head into thorax • Balance ANS – Parasympathetics mediated by Vagus n. – Sympathetics mediated by cervical ganglia Somatic Dysfunction • S/D occurs in rotation of AA joint – Rotation around vertical axis in transverse plane – AA Rotated Left or Right • Inspection – Head deviated to right or left – Chin not quite midline • Palpation – Transverse process of atlas may feel posterior or closer to mastoid process on rotated side – Transverse process of atlas may feel anterior or closer to mandible on opposite side of rotation • Motion-testing – Preference for motion in one direction, restriction in other – Active or passive Regional Scanning • Active Testing – Patient seated, rotates head to right and left – Tests total motion of typical and atypical cervicals • Passive Testing – Patient relaxes while operator takes neck into rotation – Should have more motion than active Motion Testing • Localize motion to AA joint – Forward bend head past 45° – Takes advantage of Fryette’s 3rd principle – “Locks out” typical vertebrae • Test isolated AA joint – Passively rotate patient’s head right and left – Compare degree of movement • Should be 45° in each direction – Pay attention to end feel • Normal direction should be springy • Restricted direction should feel tighter Palpatory Diagnosis • Landmarks – Lateral masses of C1 located between mastoid process and angle of mandible – Example: AA rotated left • Left lateral mass posterior, approximates with mastoid process • Right lateral mass anterior, approximates with angle of mandible • Localized motion testing – Locate C1 lateral masses – Compare motion Supine, Direct, ME • • • • • Contact lateral mass of C1 on rotated (posterior) side with MCP joint of index finger Forward bend head to 45° Rotate into barrier Sweeten with sidebending (takes advantage of Fryette’s 3rd Principle) Instruct patient to turn head in opposite direction against your force – Use isometric force for 3-5 sec – Takes advantage of obliquus capitus inferior m. • Upon relaxation, engage new barrier – Small corrections to maintain localization – Repeat 2-3 times until corrected Screen the Area • • • • • Observe. TART. Check the 1st ribs, spring ribs. Check fascia Hand on neck/shoulder: muscle tension Screen CT transverse processes ?Common compensatory pattern: SB right Rotated right (OPP pages 46-47) – OA CT TL LS: L/R/L/R – Why is Non neutral SD uncommon at the CT junction? • (assigned OPP 516-529) CT junction sagittal plane dysfunction • Often multiple segments involved – Dowager’s Hump for multiple flexed segments • Diagnostic findings for sagittal plane SD – Tissue texture changes – Alteration in relationship of spinous processes – Restiction in opposite sagittal plane motion – Rotation and Sidebending are restricted – Tenderness over the supraspinous ligament CT junction sagittal plane dysfunction • Often multiple segments involved – Dowager’s Hump for multiple flexed segments • Diagnostic findings for sagittal plane SD – Tissue texture changes – Alteration in relationship of spinous processes – Restiction in opposite sagittal plane motion – Rotation and Sidebending are restricted – Tenderness over the supraspinous ligament Posture & Landmarks • Normal Sagittal Curves: – Cervical lordosis • Concave posterior – Thoracic kyphosis • Convex posterior – Lumbar lordosis • Concave posterior – Fused Sacrum is • Convex posterior POSTURAL XRAYS MAY BE APPROPRIATE Sagittal Plane Gravitational line – Posterior to apex of coronal suture – External auditory meatus – Humeral head – Middle of L3 vertebra – Femoral head – Posterior to mid-knee/at axis – (Slightly) Anterior to lateral malleolus • Center of gravity for the entire body is ~5 cm anterior to 2nd sacral vertebra. Used to evaluate the A-P (anterior-posterior) curves of the spine Increased kyphosis/lordosis Sagittal Plane Gravitational line – Posterior to apex of coronal suture – External auditory meatus – Humeral head – Middle of L3 vertebra – Femoral head – Posterior to mid-knee/at axis – (Slightly) Anterior to lateral malleolus • Center of gravity for the entire body is ~5 cm anterior to 2nd sacral vertebra. Used to evaluate the A-P (anterior-posterior) curves of the spine Increased kyphosis/lordosis “ Transition Zones” • Areas Where Curves Reverse • Commonly susceptible to somatic dysfunction – Occipitocervical (OA), cervicothoracic(CT), thoracolumbar (TL), and lumbosacral (LS) junctions. – Boney changes in the vertebrae, muscular changes, and fascial/soft tissue changes. – Also look at the apex of the curves for dysfunction “ Transition Zones” • Areas Where Curves Reverse • Commonly susceptible to somatic dysfunction – Occipitocervical (OA), cervicothoracic(CT), thoracolumbar (TL), and lumbosacral (LS) junctions. – Boney changes in the vertebrae, muscular changes, and fascial/soft tissue changes. – Also look at the apex of the curves for dysfunction Physiologic Curves • Compensatory changes in one sagittal plane curve results in changes to other curves – e.g. Increased lumbar lordosis-> increased thoracic kyphosis and cervical lordosis • Secondary Curves Lordosis Kyphosis Decreased Curves Assess TART changes • Junctional areas, also called transitional regions, may be considered from a minimum of two segments • OA junction: OA AA C2 • CT junction: C7-T1 • TL junction: T10-L1 • LS junction: L5-S1 • Lateral Screen • C - Spine » Increased or decreased lordosis? • T - Spine » Increased or decreased kyphosis • L - Spine » Increased or decreased lordosis • Weight-bearing line through » » » » » Ext auditory meatus AC joint Body of L3 Greater trochanter Anterior to lateral malleolus Not aligned means postural decompensation View Cervical-Thoracic-Lumber Curves • Cervical Motion Test (Passive) – FB and BB (approx 90 each direction) » Test motions in superior and inferior division. » Positive test lost motion (<90 ). Must determine if loss is in superior or inferior division. 1. “Tuck Chin” FB (45 ) OA motion 2. “Untuck Chin” BB (45 ) Cervical Motion FB/BB Cervical Motion Saggital Plane: OA Cervical Motion Test – Rotation (90 each direction) » Tests both superior and inferior division » Positive test lost motion (<90 ). Must determine if loss is superior or inferior division (Best done with patient supine). Cervical Motion: Rotation