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OMM Board Review

HISTORY

AT Still born

1874

Osteopathy founded "

I

flung to the breeze the banner of Osteopathy."

1892

1 st class at American School of Osteopathy

1896

Vermont first state to license D.O.'s

1910

Flexner report

1917

AT Still dies

1918

Spanish influenza pandemic; osteopathy dramatically reduces morbidity/mortality

1962

D.O.'s exchange degrees for M.D. in California

1973

Mississippi last state to license D.O.'s

2001

Louisiana accepts COMLEX

 

OSTEOPATHIC PRINCIPLES

1. The body is a unit.

2. It has its own self-protecting and regulating mechanisms.

3. Structure and function are reciprocally related.

4. Treatment considers the preceding three principles.

AUTONOMICS

Sympathetic vs. Parasympathetic Response

Organ

Sympathetic

Parasympathetic

Pupil

Dilation

Constriction/accomodation

Ciliary Muscle

--------

Contraction

Lacrimal Gland

--------

Secretory

Mucus Glands

Inhibition

Secretory

Salivary Glands

Inhibition

Secretory

Blood Vessels (skin)

Vasoconstriction

---------

Pilomotor Muscles

Contraction

---------

Sweat Glands

Secretory

---------

Common Carotid Artery

Vasoconstriction

---------

Mucous Glands (Phx-Larx)

Vasoconstriction

Secretory

Thyroid Gland

Vasoconstriction

--------

Heart

Excitation

Inhibition

Bronchial Glands

Inhibitory

Secretory

Bronchial Muscles

Relaxation

Contraction

Upper body vasculature

Vasoconstriction

--------

Stomach

Inhibition

Motor and secretion

Liver

Glycogenolysis

Glycogen Synthesis

Spleen

Vasoconstriction

--------

Gallbladder & ducts

Relaxation

Contraction

Pancreas

Inhibition

Secretory

Kidney

Vasoconstriction

--------

Adrenal Medulla

Adrenaline

--------

Secretion

Intestinal Tract

Contraction

Relaxation

Rectal Sphincter

Contraction

Relaxation

Vesicle Sphincter

Contraction

Relaxation

Vesicle body

Relaxation

Constriction

Uterine Body

Constriction

Relaxation

Uterine Cervix

Relaxation

Constriction

Male Reproductive Organ

Ejaculation

Erection

Ovary and Testes

Vasoconstriction

(unknown)

Sympathetics Thoracolumbar outflow (T1-L2)

Head/Neck

T1-4

Thyroid

T1-4

Mammary

T1-6

Esophagus (lower 2/3rds)

T1-6

Trachea/bronchi

T1-6

Heart

T1-6 (T2 on left is most common area of somatic dysfunction for MI)

Lung

T1-6

Pleura of lung (visceral)

T1-6

Pleura of lung (parietal)

T1-11

Abdominal Viscera

T5-L2

Stomach

T5-9 (left)

Duodenum

T5-9

Liver

T5-9

Gall bladder Gall bladder (ducts) Pancreas Spleen

T5 (right) T6 (right) T7 (right) T7 (left)

Small intestine to right colon

T10-11

Left colon to rectum to pelvic organs

T12-L2

Appendix

T10 (if not presented with T10 as an option go with T12) (Appendicitis--Right twelfth rib tip is tender)

Ovary-/teste

T10-11

Adrenals

T10-11

Kidney

T10-11

Upper ureter

T10-11

Lower ureter

T12-L1

Cisterna Chyli

T11

Pelvic Viscera

T12-L2

Uterus

T12-L2

Prostate

T12-L2

Bladder

T12-L2

Upper extremity

T2-8

Lower extremity

T11-L2

Sympathetic Innervation of the GI tract

Greater Splanchnic Nerve

Stomach, Liver

(T5-9)

Celiac Ganglion

(T5-9)

Pancreas,

(10)

duodenum

Lesser Splanchnic Nerve

Small intestine

(T10-11) Superior Mesenteric

(T10-11)

Rt. Colon

(12)

Ganglion

Least Splanchnic Nerve

Left Colon

(T12-L2)

Inferior Mesenteric

(T12) & Lumbar Splanchnic Nerve

Pelvic Organs

Ganglion

(L1-L2)

Parasympathetics--cranial and sacral areas

CN III

Pupil (constriction and accomodation)

CN VII

Lacrimal/salivary glands (secretomotor) sinuses and eustachian tube

CN IX/X

Carotid body/sinus (blood pressure regulation & C0 2 /0 2 tension)

CN X

Vagus nerve (thorax. abdomen &- pelvis)

S2-S4

Mnemonic 1973 (X. IX. VII. III) Left colon and pelvis via pelvic splanchnic nerve

Parasympathetic Innervation

Nucleus/Plexus

Cranial Nerve

Ganglia

End Organs

Edinger-Westphal

Oculomotor III

Ciliary

Eye , Accomodation

Superior Salivatory Facial VII

Pterygo- Palatine & Submandibular

Inferior Salivatory

Glossopharyngeal IX

Otic

Submandibular/Sublingual gland, Lacrimal/palatine glands

Parotid

Pelvic Splanchnic

Pelvic, GU Tract Descending Colon & Rectum

Buzz words for vagus: Dysfunction of the vagus is reflected to OM, OA, AA, C1 & C2. Vagal viscerosomatic reflex from the lungs may be seen as a dysfunction of the OM. Reason for this is probably due to the ganglion nodosum, which is anterior to C2. All organs from the thyroid and below except (?) mammary glands, (?) ovaries and (?) testes. Innervates GI tract up to the middle transverse (right) colon. ALWAYS LOOK AT THE OCCIPUT, SUBOCCIPITAL, C1 OR C2 AREA FOR PARASYMPATHETIC VISCEROSOMATIC REFLEX BECAUSE OF CLOSE PROXIMITY OF VAGUS (GANGLIA NODOSUM) TO THIS REGION.

In inferior wall MI: There are many cholinergic fibers located in the inferior wall of the myocardium. Viscerosomatic reflex will be to the suboccipital region. The anterior wall MI viscerosomatic reflex is to T1-T7, predominantly T2.

Sympathetics produce epithelial hyperplasia resulting

Upper respiratory tract:

in an increase in the number of goblet cells in relation to the ciliated cells (increased goblet to ciliated cell ratio). Due to this, there is an increase in mucus production and thickening of the secretions. Parasympathetic stimulation produces the opposite. There is increased ciliated to goblet cell ratio. This helps the sweeping mechanism by the thinning of secretions.

syndrome.

PUD:

Viscerosomatic reflex due to PUD will also be to the OA/OM region. Be aware of

pepsin and acid production secreted by parasympathetic overstimulation.

This

disease

is

related

to

an

excessive

vagal

type

of

Post–Op ileus:

surgery there is an acute disruption of the intestinal system, which goes into shock. Sympathetic override inhibits peristalsis leading to post-op ileus. Rib raising is an effective treatment to tone down the sympathetic gain to the intestines.

Under sympathetic stimulation the intestines contract. During

Misc. Notes:

Pelvic splanchnic (S2-S4) vs. Sacroiliac joint (S1-S3)

Pelvic splanchnics (S2-S4) innervate from left colon down to genital cavernous tissue except adrenals.

Note: No parasympathetic innervation to the extremities.

Right vagus (AKA Posterior vagal trunk) gives rise to the celiac branch and the left vagus (AKA Anterior vagal trunk) gives rise to the hepatic branch.

The right vagus innervates the Ascending colon and the 1 st 2/3 of the Transverse colon. The left vagus innervates the liver and part of the duodenum. Therefore the right vagus is longer than the left vagus.

Rt. Vagus innervates the SA node: excess parasympathetic stimulation can cause brady arrhythmias.

Rt. Sympathetic fibers innervate the SA node: hypersympathetic stimulation may lead to supraventricular arrhythmias.

Lt. Vagus innervates the AV node: excess parasympathetic stimulation can cause heart block.

Lt. Sympathetic fibers innervate the AV node: hypersympathetic activity may lead to malignant dysrhythmias (ventricular tachycardia and ventricular fibrillation).

Sympathetics to the head and neck come from T1 to T4. Travel up to the Superior Cervical Ganglia at the level of C1 to C3, follows the arterial supply and goes through the Sphenopalatine Ganglion without synapsing continuing on to the eyes, nasal mucosa, etc.

Sphenopalatine ganglion is basically a parasympathetic mechanism mainly from CN VII. Covers throat, sinuses, ears and others.

Greater petrosal nerve carries parasympathetic fibers.

Deep petrosal nerve carries sympathetic fibers.

Hering-Breuer Reflex: Mediated by the 10 th cranial nerve occurs when the air sacs are filled with fluid. The respiratory centers receive confusing information. The vagus sends signals to decrease diaphragmatic excursion since the air sacs are filled. Concurrently, the carotid body perceives the need for more oxygen and sends signals to increase the diaphragmatic rate. The result of these signals is rapid and shallow breathing.

Autonomics Big Picture

Sympathetics

Head/Neck/Heart/Lungs:

T1-4 (6)

Upper GI:

T5-9

Lower GI/Pelvis:

T10-L2

Parasympathetics

Head/Neck:

Chest/Upper GI: X, Lower GI/Pelvis

CN111, VII, IX, X

S2-4

NEUROLOGIC (PROPRIOCEPTIVE) REFLEXES

Muscle Energy: (Golgi tendon organ reflex). (Direct method). A pull on the tendon sends signal from the Golgi tendon organ to spinal cord. At the spinal cord inhibitory interneurons synapse with alpha motor neurons causing a reflex relaxation of the muscle. When tension on a tendon becomes extreme the inhibitory effect from the organ can become so great it causes a sudden relaxation of the entire muscle. Golgi tendon organs respond to rate and changes in muscle tension. Summary: Activation of large myelinated group 1b afferent fibers from tendon insertion reflexively inhibits alpha motor neuron to muscle spindle. Buzz: Golgi, alpha motor neurons, tension/force, direct technique.

Counterstrain: Decrease gamma gain: "

shortening the muscle that contains the malfunctioning muscle spindle by applying a mild strain to its antagonist." (Jones) This is an indirect technique that employs the Muscle spindle reflex. This reflex responds to rate and changes of intrafusal fiber length. Hypershortening the extrafusal fibers by bringing the origin and insertion of the muscle mass closer together, decreases the length of the intrafusal fibers and relaxes them. This relaxation phase is followed by a slow return to neutral in order to allow the CNS to reset the gamma gain activity in the spindle to a new lower level. The end result of counterstrain on the muscle spindle fibers is a turning down of the gamma gain. Remember: Position of ease, slow return after 90 seconds. Red herrings: C3 posterior put into flexion. C4 anterior put into extension, inion put into flexion, lower pole L5 put into flexion. Key words: proprioceptor, gamma gain. Note: FPR also employs the muscle spindle reflex.

stop

inappropriate proprioceptor activity

HVLA: Can involve both the Golgi tendon organ and muscle spindle reflex. HVLA may produce changes in muscle tension and length of muscle spindles.

1. Thrust activation initiates so much afferent input into the CNS, causing the CNS to turn down the gamma gain to the muscle spindles, which relaxes the tight muscle mass.

2. During a thrust the tension on the tight muscle firmly pulls on the tendon. This activates the Golgi tendon receptors, which in turn causes a reflex relaxation to that tight muscle.

3. The stretch of the extrafusal fibers of the tight muscle pulls on the Golgi tendon receptors, which will cause a reflex activation to inhibit the contraction of the same muscle.

4. HVLA of 1/8” to 1/4” of forceful stretching of a contracted muscle may produce such a barrage of afferent impulses from the spindles to the CNS causing the CNS to respond by sending inhibitory impulses to the gamma gain cell bodies. This turns down the gamma gain activity to the spindles, thus relaxing the muscle mass via a central inhibitory reflex.

CHAPMAN'S REFLEXES

Chapman’s reflexes are a system of reflex points originally used by Frank Chapman, D.O. These reflexes present as predictable anterior and posterior fascial tissue texture abnormalities assumed to be reflections of visceral dysfunction or pathology (viscerosomatic reflexes). A given reflex is associated with the same viscus; Chapman’s reflexes are manifested by palpatory findings of plaque-like changes of stringiness of the involved tissues.

The Chapman's reflexes follow sympathetic afferent pathways and therefore are manifest along the dermatome, sclerotome and myotome segmental lines. Chapman’s reflexes are neurologic, lymphatic and myofascial reflexes that indicate increased functional activity of the sympathetic nervous system. They do not reflect the parasympathetic nervous system.

These reflexes in the thoracic area are palpated anteriorly in the intercostal spaces via sympathetic fibers of intercostal nerves. The heart reflex is located at the 2 nd intercostal space and posteriorly at T2, which is a major innervation of the heart. The reflex for the bronchus, thyroid and esophagus is also at the anterior 2 nd intercostal space.

The Chapman’s reflexes for the colon are located on the lateral thigh along the Iliotibial band and Tensor fascia lata. Also, in this same area are the reflexes for the broad ligament of the uterus and prostate. The reflex for the cecum is located at the Rt. Greater Trochanter and for the sigmoid colon at the Lt. Greater Trochanter.

Ex. Disorder in middle ear and sinuses will increase sympathetic tone to clavicle and first rib anteriorly and C2 posteriorly. They tend to follow classic viscerosomatic patterns.

OTHER TREATMENT MODALITIES

Effleurage: Form of lymphatic stroking, distal to proximal

Petrissage: Grasp, lift and twist skin to break superficial fascial adhesions.

Tapotement: Striking belly of muscle with hypothenar eminence to increase blood flow and tone

SOMATIC DYSFUNCTION

Somatic dysfunction: Is an impaired or altered function of related components of the somatic (body framework) system; skeletal, arthrodial and myofascial structures, and related vascular, lymphatic and neural elements. Mnemonic: SAM VLN. Remember TART (Tissue texture changes, Asymmetry, Restricted motion & Tenderness)

Acute:

Increase temperature (blood flow from kinins, etc).

Increase moisture (sudomotor from sympathetics).

Increased bogginess (edema from leakage of vessels and stagnant lymph) Increased tenderness (nociceptor firing in tissues).

Erythema (vascular response, redness lasts more than 15-30 seconds).

Chronic:

Decreased temperature (cool, decreased blood supply from ongoing sympathetonia).

Dryness (sustained sympathetic tone "burns out" sweat glands and decreases sudomotors).

Blanching in response to erythema streaking (sympathetics vasoconstrict blood vessels).

Ropy, stringy, soft tissues.

ERYTHEMA TEST

Acute: A positive red reflex sign due to release of substance P and other biochemical neuropeptides, kinins, etc., into soft tissues causing dilation of capillaries and inflammation. Redness shouldn't last > 30 sec.

Chronic:

sympathetic override.

There

is

a

blanching

response

due

to

excess

vasoconstriction

from

BARRIERS

Restrictive Barrier: A functional limit within the anatomic range of motion, which abnormally diminishes the normal physiologic range (1) . (Between normal midline range and physiologic barrier). AKA: Pathologic Barrier.

Physiologic Barrier: The limit of active motion; can be altered to increase range of active motion by warm-up activity .

Anatomic Barrier: The limit of motion imposed by anatomic structure; the limit of

passive motion. (End point of ligament, fascia, muscle, etc. disrupted).

Beyond these joint is

Pathologic Barrier: 1. Restrictive barrier; 2. Permanent restriction of joint motion associated with pathological change of tissues (ex. Contracture, osteophytes).

Elastic Barrier: The range between the physiologic and anatomic barrier of motion in which passive ligamentous stretching occurs before tissue disruption.

FRYETTE'S LAWS

Type I:

Sidebending and rotation to opposite sides.

Involves more than one segment (usually 3 or more) = group curve.

Dysfunction greatest in neutral (N) position.

Long restrictors maintain lesion (erector spinae).

Compensatory/gradual onset.

Treat after Type II.

Example: T3-L1 N SBI Rr: To treat put patient into RI SBr N (for muscle energy).

Type II:

Sidebending and rotation to same side.

Single segment.

Dysfunction greatest in either flexion or extension.

Short restrictors maintain lesion (rotatores brevis & intertransversarii muscles.)

Abrupt/traumatic (found at apex, beginning or end of group curve).

Treat first.

Example: T8 F SBl Rl: To treat put patient into Rr SBr E (for muscle energy).

Law III:

Named by Dr. CR Nelson in 1948: Initiation of motion in one plane MODIFIES motion in all other planes.

RULE OF THREES FOR THORACIC SPINE

A. Spinous process of segment is with its transverse process

B. Spinous process of segment is half way, to t-process of segment

T1-3

T4-6

below

C. Spinous process of seg. is at level with t-process of seg. below

T7-9

D. T10

Like "C"

E. T11

Like "B"

F. T12

Like "A"

FACILITATION

1. The maintenance of a pool of neurons (e.g. premotor, motorneurons or preganglionic sympathetic neurons in one or more segments of the spinal cord) in a state of partial or subthreshold excitation; in this state, less stimulation is required to trigger the discharge of impulses. 2. Facilitation may be due to sustained increase in afferent input, or changes within the affected neurons themselves of their chemical environment. Once established facilitation can be sustained by normal CNS activity.

3. Synapses in the cord that have low threshold are easily triggered by impulses of sublevel intensity. Visceral afferent and somatic propioceptor bombardment to the cord from visceral or somatic disease produces facilitation. These facilitated segments will then fire sympathetic outburst to related organ and soma structures when other visceral or somatic impulses pass through that region of the cord. This inappropriate sympathetic bombardment of visceral and somatic tissue will have detrimental effects to these tissues and the body in general.

DERMATOMES

C5

Clavicles

C6

Thumb

C7

Middle finger

C8

Ring/Little Finger

C5-C6

Ball of shoulder (deltoid)

C5-C7

Lateral Arm (C5 for lateral upper arm, C6 for lateral forearm)

C8-T1

Medial Inner Arm

T4

Nipple

T7

Xyphoid

T10

Umbilicus

T12

Groin

L4

Innermost foot

L5

Dorsum of foot

S1

Outermost foot

L4-L5

Medial Foot

L3-L4

Knee

L5, S1-S2

Posterior/Outer Thigh

L1-L4

Anterior/Inner Thigh

S1-S5

Perineum

T1 – In MI, T1 is probably the connection to viscerosensory pain referral to the inner arm.

Viscerosensory vs. viscerosomatic = pain vs. tissue texture changes

Pain: In general, pain above the uterine fundus is mediated by the sympathetics. Pain below (except the gonads) are mediated by the parasympathetics.

Perineum (S1-S5), very important when assessing for Cauda Equina Syndrome. Patient with large central disc herniation will have trouble with urinary or bowel retention.

KEY REFLEXES

L4

Patella (knee jerk)

L5

None (test strength of great toe dorsiflexion-extensor hallucis longus-- and

S1

heel walking) Achilles (ankle jerk/toe walking)

C5

Biceps

C6

Brachioradialis

C7

Triceps

CRANIAL

Founded in 1899 by Dr. A.T. Still's student. William Gardner Sutherland. D.O.

Five phenomena:

1. The fluctuation of the cerebrospinal fluid (or potency of the Tide)

2. The motility of the brain and spinal cord (alternating shape of CNS)

3. The mobility of the intracranial and intraspinal membranes (reciprocal tension membranes)

4. The articular mobility of the-- cranial bones joint/suture motion)

5. The involuntary movement of the sacrum between the ilium (via the dural membranes to S2)

#’s 1 and 2 are thought to be the "motive power" behind #’s 3-5

The five phenomena make up the Primary Respiratory Mechanism.

Note:

Most cranial dysfunctions are named in relation to the position of the sphenoid

bone.

Flexion: Increase in transverse diameter, decrease in longitudinal and A-P diameters.

Extension: Decrease in transverse diameter, increase in longitudinal and A-P diameters.

Torsion: Twisting of articulation of sphenoid and occiput, the sphenobasilar synchondrosis. Name lesion for side of higher greater wing of the sphenoid. Greater wing of the sphenoid is superior on the right and a low occiput on the right = Rt. Torsion.

Sidebending/Rotation: Bending of articulation of sphenoid and occiput, the SBS; the low greater wing of sphenoid is on same side as low occiput, head fuller, convex, on this side and named for this convex side (of low sphenoid and low occiput). Mnemonic: "Down and Out in Beverly- Hills". Greater wing and

occiput both inferior on the right and Sidebending/Rotation

convex (fuller) on the right

=

Rt.

Lateral Strain:

shifted to the right in relation to the occiput = Rt. Lateral Strain. Traditionally

named for which side the basisphenoid shifts towards, however, recently contested by some to be defined as to the direction opposite the sphenoid is shifted towards. It’s really an intellectual argument because they are both incorrect according to Magoun's Osteopathy in the Cranial Field. He contends that the greater wing of the sphenoid actually shifts ANTERIORLY in a right lateral strain and ANTERIORLY in a left lateral strain. Parallelogram head.

Sphenoid shifted to either right or left of occiput. Sphenoid

Vertical Strain:

sphenoid is shifted upward, for example from a punch to the bottom of the chin upward, then it’s a superior vertical strain. If shifted downward, it's an inferior vertical shear. When palpating in an A/P direction along the frontal bone and there is a dip at the coronal suture = anterior cranium is superior = Superior vertical strain. If anterior cranium (dividing line being the coronal suture) is inferior = Inferior vertical strain.

Sphenoid shifted up or down in relation to the occiput. If

A hit with a bat on head anterior to the coronal suture or a fall on the tailbone may result in an Inferior vertical strain. The later is possible since there is a change in the relation of the sphenoid and the occiput. Caution: do not name the lesion in relation to the occiput.

Compression: A-P compression at sphenobasilar symphysis, worst lesion:

overall decreased cranial motion. Described as a "bowling ball " head.

Bones:

22 cranial bones.

28 if you count the ossicles (3 in each temporal bone).

8 neurocranial bones (occiput, temporal (2), ethmoid, parietals (2), sphenoid and frontal).

14 viscerocranial bones (facial).

7 orbital bones (frontal, zygoma. maxilla, sphenoid, lacrimal, ethmoid and palatine).

29 bones in the cranium (incl. Hyoid and Ossicles)

79 articulations in the face

43 articulations in the cranium

55 articulation in the foot

26 bones in the foot

The skull has about 142 articulations. (79 face, 43 neurocranium)

Basilar bones are occiput (except interparietal portion), petrous temporals, sphenoid (except tip of greater wing) and ethmoid and are all formed in cartilage.

Vault bones are frontal, parietals, and temporals (include tip of greater wing of sphenoid and interparietal occiput). All formed in membrane and are accommodative to the basilar bones.

Sphenobasilar synchondrosis:

Major joint in cranium, formed in cartilaginous tissue, becomes cancellous bone around the age of 25 and maintains pliability, flexibility thereafter.

Movement:

Normal cranial rate is 8-14 cycles/minute. A cycle = 1 inhalation & 1 exhalation.

Cranial amplitude is quantitative 1/10 – 10/10. The latter being healthiest

Inhalation phase of the primary respiratory mechanism (PRM) = flexion of midline structures, (i.e. sphenoid, occiput, sacrum) and external rotation of paired structures (i.e. temporal bones, femur, etc.).

Exhalation phase of PRM = extension of midline structures and internal rotation of paired structures.

Occiput, ethmoid and vomer all rotate (circumducts) in the same direction in flexion and extension. Sphenoid rotates (circumducts) in opposite direction.

in the sa me direction in flexion and extension. Sphenoid rotates (cir cumducts) in opposite direction.

Landmarks:

Pterion: Overlapping of frontal parietal sphenoid and temporal. Area of anterior branch of middle meningeal artery.

Asterion: Meeting of parietal, temporal and occiput.

Opisthion: Dorsal aspect of foramen magnum.

Basion: Ventral aspect of foramen magnum.

Nasion: Meeting of frontal and nasal bones.

Glabella: Bump on distal frontal bone, above nasion.

Bregma: Meeting of coronal and sagittal sutures.

SS pivot point: Sphenosquamous point where temporal overlaps the sphenoid superior to joint and sphenoid overlaps temporal below point.

Sutherland's Fulcrum: Area of straight sinus (junction of three sickles of dura mater); automatic shifting suspension fulcrum “…point of rest on which a lever "

moves and from which it gets its power

(Magoun)

Beveling:

External bevel: Suture is on the external surface of the bone. If a bone is externally beveled it is overlapped by another bone. Internal bevel: Suture is on the internal surface of the bone. If a bone is internally beveled then it overlaps another bone.

Example: At the occipitomastoid suture the Temporal has internal beveling and the Occiput has external beveling. In this case the Temporal overlaps the Occiput.

Note: Above the SS pivot point the temporal overlaps the sphenoid and below this point the sphenoid overlaps the temporal.

When

treating a patient with a CV4 the occiput is compressed since it is overridden by the temporals.

The beveling concept gives an indication of how certain treatment would work.

The Three Articulations between the Temporal and Occipital Bones:

1. Condylosquamomastoid Pivot: Rocking motion

2. Jugular Process: occiput drives the temporal

3. Petrobasilar: Tongue and groove & Hinge/Glide motion

4. Combination of all three equals “wobble”

The Major Attachments of the Dura (Reciprocal Tension Membrane):

1. Posterior pole:

2. Lateral poles:

3. Anterior Superior pole:

4. Anterior Inferior pole:

5. Inferior pole:

Occipital bone Petrous portion of the Temporal bone Cribiform and Crista Galli of the Ethmoid Clinoid processes of the Sphenoid S2 at the superior transverse axis of the sacrum

Flow of CSF:

Lateral ventricles Interventricular foramen of Monroe 3 rd ventricle Aqueduct of Sylvius 4 th ventricle through Midline foramen of Magendie or lateral to foramen of Luschka subarachnoid space brain and spinal cord

Venous flow:

Superior Sagittal sinus Rt. Transverse sinus

Inferior Sagittal sinus Lt. Transverse sinus

Transverse sinus Sigmoid sinus Internal Jugular Vein which courses along with CN IX, X & XI and exit through Jugular Foramen which is between two bones, the occiput and temporal.

Great vein of Galen together with the Inferior Sagittal sinus Straight sinus Confluence of Sinus

Cavernous sinus empties into the Inferior and Superior Petrosal sinuses. Inferior Petrosal sinus Sigmoid sinus and the Superior Petrosal sinus Transverse sinus.

The venous sinuses lie between the two layers of dura. These veins lack smooth muscle, elastic fibers and valves. They are dependant on the mobility of the dura for drainage.

Techniques:

CV4 (compression of the fourth ventricle): Generalized technique, used in any instance except acute head trauma. Operator places thenar eminences medial to mastoid processes: encourage extension phase by holding the occiput towards you (very gently!) or away from the flexion phase. You are harnessing the "Potency of the Tide." Pronounced effect on total body physiology. For example:

The medulla is on the floor of the fourth ventricle; if you work with the CSF to alter this respiratory center you can in turn effect a change in the thoracoabdominal diaphragm and hence increase lymphatic flow from the cisterna chyli/thoracic duct via the aortic hiatus in the diaphragm (level of T12).

Sphenopalatine Ganglion: It hangs in its respective fossa via the second division of CN V, but it is supplied by the greater petrosal nerve, a branch of the geniculate ganglion of CN VII. To treat: Go to maxillary ridge near pterygoid plate and gently inhibit to effect a decrease in goblet to ciliary cell ratio and lessen thickened secretions of the nasopharynx (especially the Eustachian tube).

CRANIAL NERVE ENTRAPMENTS

Cranial Nerve

Entrapment Neuropathy

I Olfactory

II Optic

III Oculomotor

IV Trochear

V Trigeminal*

VI Abducens

VII Facial

VIII Vestibulocochlear

IX Glossopharyngeal

X Vagus

XI Accessory

XII Hypoglossal

Anosmia

Visual Acuity/Field

Eye deviation - down and out Pupils not constricting (via Edinger-Westphal Nucleus)

Eye deviation - slight upward

Anesthesia of the face, paralysis of muscles of mastication, Trigeminal Neuralgia (V2)-Stabbing pain

Eye deviation - inward, strabismus

Bells Palsy, Decreased Tears/Taste to anterior 2/3 of tongue

Decrease hearing, vertigo, Meniere's disease

Decreased swallowing

Anesthesia of External auditory meatus Circulation/Respiration changes Digestion, swallowing Swallowing/Speaking

Shoulder shrugs, swallowing

Tongue: Suckling

*Trigeminal neuralgia most commonly occurs in V2 distribution. -V1 exits via the Superior Orbital Fissure -V2 exits via Foramen Rotundum -V3 exits via Foramen Ovale

PELVIS AND SACRUM

Standing flexion Test provides information on laterality or iliosacral dysfunction. The seated flexion test provides information only on sacroiliac dysfunction, not on laterality, except to say that the side of the (+) seated flexion test is opposite the axis (named) or the same side as the inferior pole of the axis = piriformis spasm.

Example of Innominate diagnosis:

Lt ASIS - Superior Lt PSIS - Inferior Lt Pubic Bone - Superior (+) Rt Standing Flexion Test Dx = Rt Innominate Anterior Rotation

Lt ASIS - Inferior Lt PSIS - Inferior Lt Pubic Bone Inferior (+) Rt Standing Flexion Test Dx = Rt Innominate Superior Shear

Distance from ASIS to umbilicus is greater on the right, with a positive standing

flexion test on right=right outflare innominate. Distance from ASIS to umbilicus is

less on right than on left, standing flexion test positive on the right=right inflare

innominate.

outflare innominate.

Same as above but positive standing flexion test on the left=left

The axis in a sacral torsion is named for the superior pole of the axis

The “stork test” is positive for INNOMINATE or iliosacral dysfunction: Operator palpates PSIS, pt bends knee (one side) and you see if PSIS comes posteriorly. If it does NOT, then a restriction or dysfunction of the INNOMINATE/iliosacral is noted.

The “Sphinx test” just has the patient prone, in “TV watching position” to induce lumbar extension. It would make a “backward sacral dysfunction” worse. A forward sacral dysfunction would be more symmetrical.

For sacral torsion remember that L5 is rotated opposite to the rotation of the sacral rotation.

Superior transverse axis of the sacrum corresponds to Respiratory motion/ craniosacral. Middle transverse axis for sacroiliac motion and the inferior transverse axis for iliosacral motion. For all of these axes motion occurs through S2.

A question regarding a resistant ILA is referring to a posterior/inferior ILA

Anterior Superior ILA on the Rt = Posterior Inferior ILA on the Lt

Counternutation of the Sacrum = Base is posterior = Craniosacral Flexion = Postural extension

Nutation of the Sacrum = Base is anterior (nods) = Craniosacral Extension = Postural flexion

In the birthing process, as the baby comes down the birth canal the sacral base 1 st moves posteriorly in counternutation and 2 nd as the baby comes further down the apex of the sacrum moves posteriorly in nutation.

down the apex of the sacrum moves pos teriorly in nutation. Sacral Dysfunctions Torsion: By definition

Sacral Dysfunctions

Torsion: By definition deep sacral sulcus opposite from side of inferior lateral angle (ILA) being posterior-inferior. That is the sacrum moves about an oblique axis. Should have concomitant somatic dysfunction of the lumbar region (with lumbar or lumbars rotated to the opposite side of the sacral rotation). Torsions either forward (left on left. right on right) or backward (right on left, left on right). Most common: Left on left forward sacral torsion. Note: L5 must be rotated in the opposite direction as the sacrum to be a torsion. Also, the seated flexion test is generally positive on the side opposite the axis

because the inferior pole of the axis is fixed by a piriformis spasm. The superior pole of the axis is fixed by a quadratus lumborum spasm.

Rotation: L5 is rotated in SAME direction as sacrum.

Flexion/Extension lesions: Remember flexion/extension in the muscle energy model is opposite the cranial model. That is the postural and respiratory models are not to be confused. Both have an axis in the S2 region, but then, are called "middle transverse" for the postural, muscle energy model and "superior transverse" for the respiratory cranial model. If a deep sacral sulcus is on the same side of the ILA being posterior- inferior it is a unilateral sacral flexion lesion or sacral shear. For example: Deep sulcus and posterior-inferior ILA on the left = left unilateral sacral flexion lesion or left sacral shear. If both sulci deep = bilateral sacral flexion. If both sulci, shallow = bilateral sacral extension. Most common USFL/shear is on left. Mnemonic: United States Football League. You can also have a bilateral sacral flexion or extension lesion (postural model) whereby the sacral sulci are either deep or shallow bilaterally.

The fifth lumbar: Is key to the latest version of sacral dysfunction: If L5 is rotated opposite to the sacrum you most likely have a sacral torsion. If L5 is rotated in the same direction then it is a sacral rotation.

Spring test: Used to distinguish whether you have a backward v. forward sacral torsion. If the lumbars are taut, kyphotic, tense and do not spring well on compression in the prone position = positive spring test. If the lumbars retain natural lordosis and are flexible = negative spring test. Positive = backward torsion. Negative = forward torsion.

Nomenclature: Name Rotation on Axis.

Mnemonic: Rheumatoid Arthritis

= ba ckward torsion. Negative = forward torsion. Nomenclature: Name Rotation on Axis. Mnemonic: R heumatoid
= ba ckward torsion. Negative = forward torsion. Nomenclature: Name Rotation on Axis. Mnemonic: R heumatoid
Note: Spring test equivocal or negative and positive with shear. Note: Positive sitting flexion test

Note: Spring test equivocal or negative and positive with shear. Note: Positive sitting flexion test is opposite the axis in a torsion and ipsilateral in a shear. Note: Sacrotuberous ligament taut on side of posterior inferior ILA and posterior innominate.

Forward sacral torsion: In any torsion whether it's forward or backward always lie the patient on the involved axis. If left axis, lie on left side, etc. etc. For forward torsion, lie in the lateral Sims's position, that is their chest is forward on the table. Have patient flex both legs and attempt to bring both ankles toward the ceiling against your isometric resistance.

Backward sacral torsion: Patient in lateral recumbent position that is their back is towards the table. Have patient straighten out bottom leg on table, flex upper leg and attempt to bring their ankle towards the ceiling against your isometric resistance.

Unilateral sacral flexion or sacral shear: Patient prone. You place thenar or hypothenar eminence on their ILA and push cephalad and anteriorly as they exhale. Resist inhalation.

Sacral Rotations: Essential L5 is rotated in the same direction as the sacrum.

Summary:

FST: Negative spring, deep sulcus opposite post/inf ILA: lat. Sims's (forward on table 2 legs) BST: Positive spring, deep sulcus opposite post/inf ILA: lat. recumbent (back on table I leg). USF/shear: Equivocal spring, deep sulcus ipsilateral to post/inf ILA; prone position.

Primary ligaments of sacrum: Anterior interosseous and posterior sacroiliac ligaments

Accessory ligaments of sacrum: Sacrospinous, sacrotuberous and iliolumbar ligaments.

Note: Sacrotuberous ligament is taut with a post/inf ILA or posteriorly rotated innominate.

Note: Iliolumbar ligament attaches from the transverse processes of L4/5 to the

PSIS/iliac crest. symptoms.

Dysfunction here can refer pain to groin and simulate "hernia"

Sacral motion during vaginal delivery: Counternutation = base going in extension or backward about the middle transverse axis. Nutation (nodding) = base going in flexion or forward about the middle transverse axis.

THE MANY DIAPHRAGMS OF THE BODY

fossa

separating cerebellum from cortex. Area of automatic shifting suspension fulcrum (of Sutherland).

Tentorium

cerebelli:

Dura

neater

lying

transversely

on

posterior

cranial

Sibson's fascia: Thoracic inlet, measures 4 by 2 inches, attaches C7-TI around first rib to manubrium, also attaches to cupula of lung. Comprised of fascia from the scalenes and the longus colli muscles. Thoracic duct travels up through and down through this diaphragm before entering into the venous circulation (left internal jugular and subclavian or brachiocephalic veins).

Thoracoabdominal: 60% motive force for inhalation. Innervated by C3-5 somatic nerves. Hiatus for vena cava is T8, esophagus is T10 and aorta (and thoracic duct) is

T12.

Pelvic:

Comprised

of

two

muscles,

levator

ani

and

coccygeus.

Somatic

and

parasympathetic

splanchnics respectively).

innervation

by

the

cord

segments

S2-4

(pudendal

and

pelvic

Popliteal fossa: Fascial pathways for lymph from the leg.

Medial longitudinal arch of foot: Navicular and plantar fascia supportive and stress bearers.

THORACIC INLET VS. THORACIC OUTLET

Thoracic Inlet:

thorax through the thoracic inlet. It is the opening for the pharyngeal structures into the thorax and is one of the diaphragms of the body.

Structures coming from the head, neck and upper extremity enter the

Keep in mind that these diaphragms assist in maintaining the intracavitary pressures (intrathoracic {-}, pharyngeal {+} and abdominal/pelvic {+}). The maintenance of these pressure gradients is vital for fluid movement.

The thoracic duct travels up through the thoracic inlet to the level of C7, then reenters the thoracic cavity through the thoracic inlet to empty into the venous system.

Buzz words for the thoracic inlet: Sibson's fascia and suprapleural membrane. These keep the pharyngeal structures from being "sucked" into the thorax by the negative pressure in the thoracic cavity.

Structures Apices of the lungs Trachea Esophagus Brachiocephalic veins Vagus Cervical symphathetics Phrenic Nerve Thoracic Duct

Thoracic Inlet

Functional T1, T2, T3, T4 Ribs 1 & 2 Manubrium

Anatomic Manubrium Ribs 1 & T1

Thoracic inlet assessment: This is used to assess the dimension of thoracic inlet torsion. Example:

If the left coracoclavicular angle is anterior or more convex = right coracoclavicular angle is deep = Thoracic inlet is rotated to the right. If left rib is elevated = Thoracic inlet is sidebent to the right.

Rotation is assessed by the coracoclavicular angle or infraclavicular

fossa. Sidebending is determined by an elevated 1 st rib.

Thoracic Outlet: Structures leave the thorax through the thoracic outlet mainly to the upper extremities.

Thoracic Outlet

Clavicle 1 st rib Neurovascular Bundle

Downward displacement of the clavicle onto the 1 st rib may cause compression of the neurovascular bundle resulting in thoracic outlet syndrome. Compression of the subclavian artery and brachial plexus may occur: (1) As these structures pass through the triangle formed by the 1 st rib and the anterior and medial scalenes; (2) As the

neurovascular bundle passes between the pectoralis minor near its attachment to the coracoid process and the rib cage.

COMMON COMPENSATORY PATTERN OF ZINK

Dr. Zink described patterns of fascia, which alternated direction at certain anatomical junctions (OA, Thoracic Inlet, Thoracolumbar area, Lumbosacral area). These junctions coincide with diaphragms of the body. According to Dr. Zink the alternating fascial patterns are the body’s response to provide postural compensation. Most common pattern is L, R, L, R.

OA-- Rotated to left.

Thoracic inlet-- Rotated (and side-bent) to right

Thoracolumbar junction-- Rotated to left

Lumbosacral junction-- Rotated to right

Note: This is the most compensatory (physiologic) pattern of fascial directions. As long as it alternates L-R-L-R (80%) or R-L-R-L (20%) this is good. Very dysfunctional to have R-L-L-R or R-R-R-R, etc.

good. Very dysfunctional to have R-L-L-R or R- R-R-R, etc. LYMPHATICS Right minor system vs. Left

LYMPHATICS

Right minor system vs. Left main thoracic drainage. Right upper extremities, Rt. Hemicranium, heart and lungs (except the Left upper lung) drains into the right thoracic duct. The right thoracic duct in turn drains into variable sites one of which is the Rt. Brachiocephalic vein. The left thoracic duct drains into the junction of the Subclavian and Internal Jugular veins.

Ex: Lymphangitis of the Lt. Foot will eventually drain in the Lt. Thoracic duct and an abscess of the Rt. Index finger would drain into the Rt. Thoracic duct.

SPINAL CORD/COLUMN

Facets of cervical spine are oblique. Facets of thoracic spine are coronal. Facets of lumbar spine are sagittal.

Cervical spine:

OA = flexion/extension (50%) AA = rotation (50%) C2-7 = increasing sidebending as you proceed distally

Spinal cord:

Ends at L1-2 vertebral level (L3 in infant) Thirty-one pairs of nerve roots (8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal)

SCIATIC NERVE

Comprised of L4-L5 and S1-S3

Peroneal portion pierces belly of Piriformis 10% of population. Most often exits inferior to muscle and 0.5% exits superiad to muscle.

“Sciatica” is a lay term to describe a syndrome of chemical irritation of the nerve bundle, usually related to piriformis spasm, in which pain does not extend below the knee.

Note: “Psoas syndrome” usually involves contralateral piriformis spasm.

MUSCULOSKELETAL PATHOLOGY

Herniated Disc Herniated intervertebral disk (herniated nucleus pulposus): A posterior-lateral herniation of the nucleus pulposus through the posterior longitudinal ligament. Most common between L4-5 and L5-S1 vertebral segments. Specifically, however, the fifth lumbar disk (btw L5-S1) is the most commonly herniated.

Lower extremity radiculopathies are mainly from L5-S1. Which nerve gets impinged in a disc herniation at L5-S1? L5 or S1? The nerve root that is affected is S1. Herniations affect the nerve root of the lower vertebral level. (See Netter’s plate no. 149).

Spondylolisthesis

Most common type is isthmic spondylolisthesis (Type IIA). It is also the most common cause of lower back pain in the pediatric population.

Spondylolisthesis is a primary defect of the pars interarticularis.

Anterior slippage of one vertebra on its subjacent vertebra. Most commonly L5 slips forward on S1.

Most commonly occurs in the general population of < 50 y.o.

The affected children will have an exaggerated lumbar lordosis, high gluteal crease line and tight hamstrings. The hamstrings innervation is between L5-S1 nerve roots. The nerve roots are not necessarily impinged but they are affected and cause somatosomatic reflex.

A Scotty dog seen on X Ray is a sign for spondylolysis:

Collar: Microfracture between the superior and inferior articular facets

Eye:

Pedicle

Hind leg:

Spinous process

Fore leg: Inferior articular facet Nose: Transverse process

Spondylolysis: Defect in the posterior neural arch (pars interarticularis which is at the junction of the superior and inferior articular facets): usually bilateral; postulated as microfractures sustained over time; gives rise (usually) to

Spondylitis: Inflammatory arthritis of the spine begins at sacroiliac, joint and ascends up spine then extremities, males, 15-30 years old.

Spinal stenosis: Result of DJD/disk degeneration; spinal foramen closes due to calcium build up and compromises spinal cord (normal AP diameter of canal is 1.2-1.5 cm). Gives rise to pseudoclaudication" in which radicular symptoms are worse in lumbar extension, for example, standing or walking. Symptoms are better with lumbar flexion, for example sitting. "Pseudo" because true aortic-iliac plaque stenosis would give leg pain/paresthesias that are relieved by simple rest, i.e. standing, which would not relieve cord compromise (spinal stenosis).

L5: Best answer for the vertebra with “the most common congenital malformations”.

Some Tests:

Sitting flexion: Tests sacroiliac dysfunction

Standing flexion: Tests iliosacral dysfunction

Trendelenberg: Tests strength of gluteus medius. > 15 degree pelvic drop = (+).

Hip Drop: Tests lumbar sidebending capability on opposite side

Lachman: Tests anterior and posterior Collateral ligament laxity/rupture with knee semi-flexed

Allen (modified): Tests ulnar and radial collateral circulation of the hand

Finkelstein's: Tenosynovitis of the tendon sheath of the extensor pollicis brevis (De Quervain's disease), at the radial wrist

Straight leg raising: Puts tension on the sciatic nerve epineurium from a disk impingement.

RIBS

Pump

a

transverse axis. Bucket handle: Ribs 6-10, smaller "spinotransverse angle", favors motion about an AP axis.

handle:

Ribs

1-5;

larger

"spinotransverse

angle",

favors

motion

about

Treatment involving muscle energy:

Rib 1: use anterior and middle scalenes

Rib 2: use posterior scalenes

Ribs 3-5 (6): use pectoralis minor

Ribs 6-9: use serratus anterior

Ribs 10-11: use latissimus dorsi

Rib 12: use quadratus lumborum

Inhalation restrictions: Equals "exhalation somatic dysfunction", the rib is caught expired, held and stuck down.

Note: TREAT UPPER RIB IN RIB GROUP STUCK DOWN

Exhalation restrictions: Equals "inhalation somatic dysfunction", the rib is caught inspired, held and stuck up. Treatment involving respiratory cooperation will have operator increasing thorax flexion for pump handle ribs and increasing thorax sidebending for bucket handle ribs as patient exhales.

Note: TREAT LOWER RIB IN GROUP STUCK UP

Ribs 11 & 12:

Eleventh and Twelfth rib motion is caliper or pincher like motion. Inhalation will move these ribs upward and outward. Exhalation will move them downward and inward. The latissimus dorsi pulls the 11th and 12th ribs up, while the quadratus lumborum pulls the 12th rib down.

UPPER EXTREMITY

Shoulder has seven articulations (five true and two false): The costovertebral joint of the first rib, the costosternal joint of first rib, the sternoclavicular, acromioclavicular and the glenohumeral joints are all true shoulder joints. The scapulothoracic and suprahumeral joints are false shoulder joints.

Rotator cuff: Mnemonic: SITS muscles for Supraspinatus, infraspinatus, teres minor and subscapularis. Does little rotation, however, stabilizes and maintains glenohumeral joint function, especially holding head of humerus in glenoid fossa and gliding it inferiorly during abduction.

SITS: C5 somatic nerve

Falling on outstretched hand will tear infraspinatus and teres minor and dislocation humerus posteriorly. Additionally, it will facilitate a posterior radial head dysfunction at the elbow. Also, lateral cord of brachial plexus compromised against coracoid process leading to paralysis or paresis of cuff muscles.

Rotator cuff tear: Most common tendon torn is supraspinatus. Test: Jobe or Drop Arm. common after age 40 due to lifetime of Gravitational stress on tendon with resultant weaker arterial supply to muscle.

Spencer techniques for shoulder: (for glenohumeral motion restrictions)

Extension

Every

Flexion

Fine

Circumduction

Cartoonist

Circumduction with traction

Creates, then

Abduction

Abounds

Internal rotation

In Red

Abduction with traction

Abs tracts”

Elbow dysfunction: Hyperpronation of forearm such as a forward fail onto the palm creates a posterior radial head lesion. Tx: Hypersupinated, extend and thrust radial head anteriorly.

Elbow dysfunction: Hypersupination injury, such as falling backward and landing on the palm creates an anterior radial head. Tx: Hyperpronated, flex and thrust radiaI head posteriorly.

Remember: Pronation = posterior radial head. Supination = anterior radial head

Reciprocal motion of forearm: Abduction of distal ulnar causes medial glide of olecranon and adduction of wrist joint with resulting distal glide of proximal radial head.

Wrist dysfunction: Restricted extension due to ventral glide of proximal carpal bones (scaphoid, lunate and triquetral) is most common. Lunate usual trouble maker. Carpometacarpal joint of thumb: Saddle shape, great motion (except axial rotation), therefore susceptible to somatic dysfunction.

Other carpometacarpal joints: Somatic dysfunction with dorsal glide.

Note: Gliding motions, which are considered minor motions, are the major area of somatic dysfunction in the extremities.

LOWER EXTREMITY

Femur: 1/3 length of human body. Has four axes: A-P (abduction 55, adduction 35), transverse (flexion 85-130, extension 35), anatomical longitudinal (along shaft of femur), and functional longitudinal (internal & external rotation: from line imagined from ASIS to patella).

Note: Internal rotation of femur equals a relatively shortening of the leg. (Kuchera)

Note: External rotation of the femur equals a relatively lengthening of the leg. (Kuchera)

Knee dysfunction: Due to restricted gliding motions. Remember 6 glides: Posterior, anterior, medial, lateral and anterior-medial (increased with knee flexion) and posterior- lateral (increased with knee extension).

Usual somatic dysfunction of the knee are anteromedial, medial and posterior glide. (Kuchera)

Anterior cruciate ligament:

test)

Keeps tibia from gliding anteriorly on femur. (Lachman's

Posterior cruciate ligament: Keeps tibia from gliding posteriorly on femur.

Fibular head: Reciprocity of Proximal and distal fibula: External rotation of the tibia and ankle will carry the distal fibula posteriorly and will elevate and glide the proximal fibular head anteriorly." This is the basis for the HVLA thrust with a posterior fibula head.

Opposite occurs with internal rotation of tibia and inversion of ankle.

Plantar flexion of the ankle tends to create a posterior fibular head

Dorsiflexion of the ankle tends to create an anterior fibular head

Joint configuration of proximal tiblofibula joint is oblique therefore glide is actually posterior-medially, or anterior-laterally.

HVLA treatment for posterior fibular head therefore involves thrusting the proximal fibula head both anteriorly and laterally while flexing the knee, externally rotating the tibia and everting the ankle to engage and breakthrough restrictive glide barrier.

Usual somatic dysfunction of ankle joint occurs in plantar flexion when the talus glides anteriorly, that is ankle is restricted in dorsiflexion and the talus is restricted in posterior glide.

HVLA treatment for anterior talus is "tug" thrust with ankle locked out in dorsiflexion.

Somatic dysfunction of the navicular bone is plantar glide plus internal rotation (about an AP axis) of its plantar surface.

Somatic dysfunction of the cuboid bone is plantar glide plus external rotation (about an AP axis) of its plantar surface.

Somatic dysfunction of cuneiforms is plantar glide.

HVLA treatment for navicular, cuboid and cuneiform is "Hiss Whip Maneuver". You literally whip the tarsals dorsally with thrust contact on plantar surface of foot.

Note: Again, somatic dysfunction of the extremities tends to involve a restriction in gliding motion.

Note: To paraphrase Dr. Korr: In any disease process there will be hypersympathetic tone. If you have a sustained injury in the extremities and develop, say, reflex sympathetic dystrophy, you must treat the cord levels that supply sympathetics to the extremities. Thoracic cord segments T2-8 supply the upper extremity; thoracic cord segments T11-L2 supply the lower extremity.

SUPINATION INJURY OF THE ANKLE

Most common form of strain/sprain of the ankle is supination injury. Supination of the ankle involves:

Inversion

Plantarflexion

Adduction

Biomechanics of Supination injury of the Ankle

Structures

Motion

Talus

Moves posteriorly

Fibular head

Moves posteriorly

Innominate (via Biceps Femoris) Rotates posteriorly

Sacrum

Superior oblique axis,

Tibia

usually on the same side of the somatic dysfunction Anterior medial glide

Femur

Internal Rotation

Navicular

Plantar/Medial glide

Cuboid

Plantar/Lateral glide

Pronation of the ankle involves:

Eversion

Dorsiflexion

Abduction

Inversion sprain affects the anterior talofibular ligament. An eversion sprain affects the deltoid ligament.

Ligaments most commonly affected in an ankle sprain are the anterior talofibular, calcaneofibular and posterior talofibular (in this order).

SHORT LEG SYNDROME

Heilig formula:

Lift required (L) = Sacral base unleveling in inches (SBU) Duration (D) + Compensation (C)

Duration:

1 = 1 to 10 years

2 = 10 to 30 years

3 = > 30 years

Compensation:

0 = Sidebending only

1 = Rotation toward the convexity

2 = wedging, altered facets

Example: 50 y.o. patient with a 1/4" SBU for the past 31 yrs with a compensation of rotation toward the convexity, similar to that of a Type I group curve, with no major spinal deformities (no zygopaphyseal or facet deformity, no wedging of the vertebra).

SBU = 1/4 "

= 1/16"

Duration (3) + Compensation (1)

If structural short leg (congenital, etc) the ASIS will be low and the medial malleoli high on the side of the short leg.

Functional compensation (due to sacral torsion, etc) the ASIS will be higher on the side of the higher malleoli. A higher ASIS in posterior rotation of the Innominate can be related to short leg only if it is compensated.

Any sacral base unleveling of greater than 5 mm should be addressed

Dropped sacral base will result in a short leg. May use lift therapy to correct the short leg. Use Heilig to determine the lift required.

The side of SBU is the side where the lumbar convexity will be found. This is where the body begins to compensate.

The final analysis for a heel lift will be different by a 50 to 75% less than the original X-Ray findings. This is due to X-Ray distortion of bone size.

Pelvis rotates and sideshifts towards the long leg side

There is an increase in the lumbosacral angle of 2 to 3 degrees

The shoulder will be low on the opposite side of the SBU

Fragile/Acute pain/Aged, osteoporosis: 1/16" q 2 wk. Do not start with more than

1/16"

Patient is stable: 1/8" q 2 wk

Sudden loss (Acute fracture): restore full amount/length, this is to prevent compensation by the body.

Up to1/4” replaceable heel lift can be used inside the shoe

Up to1/2" total heel lift can be placed between the heel of the patient’s foot and the floor. This can be 1/4" inside the shoe & 1/4" to the heel of shoe. Not more than 1/4” of the total heel lift can be placed inside the shoe.

An increase beyond a 1/2” heel lift must be added to the heel and to the anterior half sole. Ex: If heel had been lifted 1/2” and an increase of 1/4” was required:

1/4” would be added to the heel and 1/4” to the anterior half sole.

Heel lift rotates pelvis opposite side

Sole lift rotate pelvis same side

Therefore if lift > 1/2" need half sole

Lift therapy will elevate the lower extremity and sacral base and also rotate the pelvis to the opposite side. This rotation of the pelvis needs to be addressed when the lift is > 1/4". In this case you need an anterior half sole to help bring back the pelvis to midline.

PSOAS SPASM

A psoas spasm will give you a non-neutral (Type II, flexion or extension) somatic dysfunction at L1 and L2.

The psoas originates from T12-L5 and inserts into the lesser trochanter of the femur

Somatic nerves to the psoas are T12-L3. A psoas spasm can cause a contralateral piriformis spasm leading to a piriformis syndrome with pain referral to the L2 range. The nerve supply to the piriformis is S2.

A spasm of the piriformis will be the cause of an Inferior pole in a sacral torsion. The spasm anchors the inferior pole of the oblique axis. Sidebending of the lumbar spine will anchor the superior pole of the oblique axis.

The psoas can go into spasm in a patient that is passing a renal stone through the ureters. Psoas spasm may also affect ureteral function since the ureters descend on the fascia of the psoas.

SPECIFIC MUSCLE ACTIONS

Muscle Suboccipital muscles Intertranversarii Rotatores Brevis Splenius Trapezius Semispinalis Longissimus

Action Extends and rotates head to same side Bends column to same side Rotates column to opposite side Extends, sidebends & rotates to same side Extends & sidebends toward; rotates away Extend and rotate to opposite side Extends, sidebends & rotates to same side

**Erector Spinae: Iliocostalis, longissimus & spinalis

RANGE OF MOTION BY REGION

Region

Cervical

Thoracolumbar

Range of Motion

Muscles

Flexion - 45 degrees Extension - 90 degrees

Sidebending - 45 degrees SCM/Scaleni/Spleni/ES

Rotation - 90 degrees

SCM/Scaleni Trapezius/Spleni/Erector Spinae

SCM/Scaleni/ES/Spleni *SCM & Scaleni rotate opposite Rectus Abdominis/psoas Erector Spinae

Obliques/ES

Flexion - 45 degrees Extension - 45 degrees

Sidebending - 45 degrees ABS/ES/Quadratus Lumborum/psoas

Rotation - 45 degrees

REMEMBER: Range of motion only comprises 1/4 th of somatic dysfunction!!! T.A.R.T. Try to alleviate and improve the others.

GATE THEORY OF WALL AND MELZACK

According to this theory, the substantia gelatinosa acts as a gating mechanism for the control of afferent input to the spinothalamic neurons. The activity in pain carrying slow, small unmyelinated C fibers keep the gates open and activation of fast, large myelinated A delta fibers closes the gate. Impulses carried by the larger faster fibers are thought to cause synaptic inhibition of the tracts carrying pain perception (C fibers). Under this gate control theory, on the basis of all afferent stimuli, the neurons of the spinal cord would decide whether or not a particular event should be reported to the brain as being painful.

The spray and stretch technique for the treatment of trigger points is believed to act through this theory. "The vapocoolant or TENS unit activates cold sensitive receptors

which report centrally via fast fibers. The afferent volley conveyed through these fast fibers blocks the trigger point nociceptive impulses transmitted by slow fibers at the substantia gelatinosum (lamina 5). This allows the operator to stretch the muscle containing the trigger point without pain or reflex spasm."

the trigger point wit hout pain or reflex spasm." Coolant Spray(or TENS) Deep pain is blocked

Coolant Spray(or TENS)

Deep pain is blocked

Krause fibers Muscles can be stretched and reset Gate is blocked(dorsal horn)
Krause fibers
Muscles can be stretched
and reset
Gate is blocked(dorsal horn)

PAIN

Fast fibers ascend the cord via the neospinothalamic tracts (new). Slow fibers ascend the cord via the paleospinothalamic tracts (old).

The fibers enter the dorsal horn, may ascend or descend a few segments, synapse at the substantia gelatinosa which precedes the posterior grey matter, then cross over the cord to ascend ultimately to among other areas the thalamus (and periaquaductal grey matter of the ventricles) and cortex.

Pain from the viscera is transmitted via the sympathetic nerves. Exceptions include the cervix, upper vagina, bladder trigone, prostate and the esophagus, trachea, and main

. Remember, however, that

bronchi, which transmit pain via the parasympathetics

there are no parasympathetic fibers in the extremities. Autonomic mediated pain from an extremity (reflex sympathetic dystrophy) is the result of sympathetic activation and During inflammation of an organ, the appendix for example, pain is first recorded in the “visceral layer” which obviously refers pain to the embryological origin (around the umbilicus) then inflames the “parietal layer” (and peritoneum) which stimulates the somatic nerves which are dermatomally related, in this instance to the right lower quadrant of the abdominal wall. Thusly the pain of appendicitis “moves” because of different neural activation; first the visceral then somatic. In addition, the organs are insensitive to burning, cutting, heat and cold but are sensitive to traction, distension, anoxia or contractions.

(2)

FIBROMYALGIA

Pathogenesis and Clinical Presentation:

traumatic event.

Disturbances of stage 4 (non-rapid eye movement, non-REM).

and fatique. Total body pain for greater than 3 months in at least 11 of 18 areas:

Largely unknown. Look for a preceding

Abnormal levels of serotonin and norepinephrine and substance P.

Female, pain, stiffness

1. Occiput, suboccipital mm

2. Low cervical, anterior intertransverse process space C5-7

3. Trapezius

4. Suprapinatus

5. Second rib at costochondral junction

6. Lateral epicondyle

7. Gluteals

8. Greater trochanter

9. Knee (medial knee fat pad)

Note: 9 areas bilaterally equals 18 total. You need at least 11 of the above (bilaterals count for two areas) to secure a diagnosis of Fibromylagia. In addition, axial spinal pain is important as Is having pain in 3 of the four quadrants of the body; ie, “my right arm, back and both lower extremities hurt all the time.”

Treatment

Cardiofitness

includes

OMT,

Tricyclics,

SSRI’s,

Cognitive

Behavioral

Therapy,

MISCELLANEOUS TIDBITS

1 st rib: most dysfunctions are of exhalation restriction. Rib is stuck up.

In a question regarding scoliosis that only refers to the side of the convexity of the curve, this will indicate the side of the rotation. Sibebending will be opposite. Ex: convexity to the right = rotated right, sidebent left.

Piriformis tenderpoint for counterstrain is between the PSIS and the Greater Trochanter.

L5 nerve root supplies motor innervation to the extensor hallicus longus.

Muscles of the Pelvic Diaphragm = Levator Ani and Coccygeus. The innervation is from S2-S4

The first rib that you feel below the tip of the scapula is the 8 th rib. Important landmark for centesis of the pleura.