Bullshit OPP 2 Flashcards
SI joint characteristics
diarthroidial-hylaine and fibrocartilidge
formclosure keystone anatomy gravity pushing it down in
force closure from ligaments
psoas syndrome
flexed forward pain radiates to anterior thigh and sidebending to same side, decreased hip extension, imporvement of pain when thigh flexed
location of psoas tender point
2 inches medially and 2 inchs inferior from asis
piriformis syndrome
origin anterior surface of sacrum inserts greater trochanter of femer
-pain in butt radiates doen leg
decreased internal roation with extended hip, decreased adduction with flexion
left pyriformis syndrome name sacral diagnosis
right on right
right pyriuformis syndrome name sacral diagnosis
left on left
innominate rotaions with functional vs anatomic
functional; short leg=post rotation
long leg=anterior rotation
anatomic is opposite due to compensation
know heel lift guidlines
fragile: 1/16 inch lift every 2 weeks
healthy: 1/8 inch lift initial and the 1/16 every week or 1/8 every 2 weeks
sudden loss: lift full amount
tender point for pyriformis syndrome
8cm medial to the greater trochanter on same side
left psoas syndrome sacral diagnosis
left on left sacral
right psoas syndrom diagnosis sacral
right on right sacral
where is psoas major tender point
Location: Two inches inferior and two inches medial from ASIS (press posterio-laterally)
counter strain technique psoas major?
flex extertnally rotate both legs place on thigh physician on same side flex and sidebend toward TP
transverse axis of motion of sacrum?
- Superior (Respiratory) at S1:
Thoracic respiratory and Primary Respiratory motions in the sacrum occur around this axis - Middle at S2:
Postural motion of the sacrum opposite the lumbar spine - Inferior Transverse Axis at S3:
The innominates rotate around this axis
Iliosacral motion
what axis does the asis compression test check?
inferior transverse axis ileosacral motion
MET absolute contraincations
fracture, dislocation or joint instability
MET superior pubic shear
patient supine doctor on same side leg off table abduct leg until motion at pubic symphysis, extend leg to feather edge of barrie, place hand on contralateral ASIS, instruct patient to push leg antero medially resist do three or four times recheck
MET inferior pubic shear
patine supine flex patient leg to feather edge of barrier moving innominate posteriorly have patient push knee inferior laterally
MET for pubic compression
alternate adduct abdcuct forces with one fist then two fists
MET for anterior rotated innominant
. Place patient’s right knee against physician’s shoulder closest to the patient.
- Flex the patient’s hip to the feather edge of the restrictive barrier, moving the innominate posteriorly.
- With cephalad hand reach under and contact ischial tuberosity to guide posterior rotation of the innominate or brace opposite ASIS.
- Instruct the patient to push their knee inferiorly into physician’s shoulder while providing isometric counterforce.
- Maintain this contraction and counterforce for 3-5 seconds.
- Instruct the patient to relax.
- Wait until the tissues relax (at least 2 seconds), then re-engage the feather edge of the barrier.
- Repeat steps 3-6 two to four more times or until no further change is noted.
- Return to neutral.
- Reassess.
MET posterior rotated innominant
supine leg off table extend to feather edge have patient move leg anterior have hand on opposite asis
MET pubic inflare
flex knee to 90 induce external rotation by pulling knee laterally feather edge resist
MET pubic outlfare
flex to 90 adduct knee have patient push laterally featehr edge
MET superior innomintat shear
supine abduct and flex or extend internally rotate pull back have patient resist feather edge
MET inferior pubic shear
prone flex knee to 90 fist on ischial tuberosity push it superior have patint push foot cuadally into physician
counter strain pyriformis tender point
Patient Position: Prone
Initial Position: Thigh hanging off the table, flexed to 135 degrees, abducted, fine tune with external rotation
L5 rule for sacrum
sacral torsion and L5 are always rotated opposite eachother
forward sacral torsion means what kind of mechanics in lumbar spine
Forward sacral torsions occur with NEUTRAL mechanics in the lumbar spine. (Type 1)
backward sacral torsion occurs with what mechanics in lumbar spine
Backward sacral torsions occur with NON-Neutral mechanics in the lumbar spine. (Type 2)
left on left sacral torsion what is L5 diagnosis? (ROSS)
L5 is rotated to the RIGHT, and sidebent left.
how do you find the sacral sulci?
moving medial and slightly superior to the PSIS bilaterally.
Where is the inferior lateral angles of the sacrum (ILA)
most posterior/inferior aspect of the sacrum is the level of the
How is the sacral flexion test performed and which side is positive?
seated, side that moves first and farthest is positive
In sacral torsions the seated flexion test + side is what in reference to the dysfunction and what to the oblique axis?
ipsilateral to the dysfunciton but contralateral to the oblique axis
In sacral sheers the + side is what to the dysfunction?
ipsilateral to the dysfunction
which test determines left or right for sacrum diagnosis?
seated flexion test is a lateralizing test
a straight posterior force at the level of the PSIS evaluates which sacral transverse axis?
middle transvers axis should coorelate to seated flexion test
What are the criteria for a positive and negative ASIS compression test
A negative test will have a small amount of free motion of the ilium with respect to the sacrum before the entire pelvis begins to rotate. In addition, there will be a ligamentous (firm but not bony) end-feel.
A positive test will have NO motion of the ilium with respect to the sacrum, and the pelvis will rotate immediately. Repeat the procedure on both sides.
what sacral test determines anterior vs posterior?
sacral spring test
what would a positive sacral spring test mean?
no spring sacrum is stuck backward
increased or unchanged asymetry of the sacral landmarks when a patient moves into the sphynx position would indicate what for the sacrum?
sacrum prefers posterior motion extension type dysfunciton
improvement of assymetry of the scarum when the patient moves into the sphynx position would indicate what for sacral diagnosis?
sacrum prefers anterior motion (flexion type dysfunciton)
which test is considered the most reliable of all sacral tests?
motion testing
what would indicate a unilateral sacral flexion?
The slippage of one sacroiliac joint about a vertical axis with translation of the sacral base (the sacrum appears to be side bending on an A-P axis).
Positive seated flexion test (usually) on dysfunctional side.
Spring test NEGATIVE (forward motion present)
Sulcus deep on same side as positive seated flexion test
ILA posterior on same side as positive seated flexion test
what would indicate a unilateral sacral extension?
The slippage of one sacroiliac joint about a vertical axis with translation of the sacral base (the sacrum appears to be side bending on an A-P axis). Positive seated flexion test (usually) on dysfunctional side. Spring test POSITIVE (forward motion ABSCENT) Sulcus shallow (posterior) on same side as positive seated flexion test ILA anterior (deep) on same side as positive seated flexion test
what determines a bilateral sacral shear?
Negative (or equivocal) seated flexion test.
Bilaterally Positive ASIS Compression Test
Exaggeration of normal flexion or extension.
Sacral sulci equal but excessively deep or shallow.
ILA’s are equal but excessively deep or shallow.
The sphinx/spring test will determine flexion or extension.
Positive spring test (spring is absent) = Extension
Negative spring test (spring is present) = Flexion
how do you treat forward sacral torsions?
Up UP UP or down down down (These refer to the Axis, the patient’s face, and the doctor’s force respectively)
up up up treatment steps for sacral torsion?
Axis is UP (patient lying on dysfunction side)
Flex patient’s knees and hips to localize force to L/S junction from below.
Rotate patient’s shoulders so his face is UP (supine from the waist cephalad) to localize force to L/S junction from above.
Physician brings patient’s ankles UP toward the ceiling (Doctor’s force is UP).
Monitor at dysfunctional base (one nearer the table)
Patient isometrically contracts to bring ankles toward the floor as physician resists. 3-5 seconds.
Patient relaxes. Physician takes up the slack. Repeat 3-5 times
Reassess the sacrum
down down down treatment steps for sacral torsion?
Axis is DOWN (patient lying axis side)
Patient in Sim’s position (side-lying with face DOWN “hugging the table”)—this localizes to L/S junction from above.
Flex patient’s knees and hips to localize force to L/S junction from below.
Monitor at dysfunctional base (one nearer the ceiling)
Physician presses patient’s ankles DOWN toward the floor (Doctor’s force is DOWN).
Patient isometrically contracts to bring ankles toward the ceiling as physician resists. 3-5 seconds.
Patient relaxes. Physician takes up the slack. Repeat 3-5 times
Reassess the sacrum
treatment for backwards sacral torsions?
down up down
Axis is DOWN (patient lying axis side)
Rotate patient’s shoulders so his face is UP (supine from the waist cephalad) to localize force to L/S junction from above
Flex patient’s knees and hips to localize force to L/S junction from below.
Extend lower leg.
Drop upper leg off the table.
Monitor at dysfunctional base (one nearer the ceiling)
Physician presses knee/ankle DOWN towards the floor (Doctor’s force is DOWN)
Patient isometrically contracts to bring knee/ankle toward the ceiling (external rotation of the hip) as physician resists. 3-5 seconds.
Patient relaxes. Physician takes up the slack. Repeat 3-5 times
Reassess the sacrum
treatment for unilateral flexion scaral
IN IN IN
Physician abducts the ipsilateral leg to open the SI joint—approximately 15o
Physician INternally rotates ipsilateral leg (patient maintains this position)
Physician contacts the ipsilateral INferior lateral angle with his thenar eminence and introduces an anterior (ventral) springing force to the point of maximal barrier.
Patient is instructed to INhale maximally and hold. Physician maintains force when the patient exhales.
Repeat 3-5 times with forceful inhale.
Reevaluate the sacrum
unilateral extension treatment
ex ex ex
Physician abducts the ipsilateral leg to open the SI joint—approximately 15o
Physician EXternally rotates ipsilateral leg (patient maintains this position)
Patient EXtends lumbar spine (Sphinx position—bringing the sacrum toward flexion)
Physician contacts the ipsilateral sacral base with his thenar eminence and introduces an anterior (ventral) springing force to the point of maximal barrier. (may use a counter force on ipsilateral ASIS)
Patient is instructed to EXhale maximally and hold. Physician maintains force when the patient inhales.
Repeat 3-5 times with forceful exhale.
Reevaluate the sacrum
bilateral flexion sacral treament
in in in
Abduct both legs to area of maximum relaxation of both S/I Joints – usually 15° to 20°
Internally rotate both hips
Monitor the base bilaterally
Spring over the ILA’s to find the angle which produces the greatest spring at the sulci. Avoid the coccyx!!
Induce a cephalad and anterior force over the ILA’s as the patient inhales deeply, repeating 3-5 times.
Reassess the sacrum
bilateral extension
ex ex ex
Patient in sphinx position
Abduct both legs to area of maximum relaxation of both S/I Joints – usually 15° to 20°
Externally rotate both hips
Monitor the ILAs bilaterally
Spring over the base bilaterally to find the angle which produces the greatest spring at the ILAs.
Induce a cephalad and anterior force over the base as the patient exhales deeply, repeating 3-5 times.
Reassess the sacrum
chronic neck pain is after what period of time
6 months
c5 neurological level
motor is deltoid and biceps
dermotome is lateral half of bicep and shoulder ish
c6 neurological level
Wrist Extensor Group (Radial Nerve)
Brachioradialis Reflex
Sensation to Lateral Forearm (Musculocutaneous Nerve) and thumb and pointer finger
c7 neurological level
Triceps (Radial) & Wrist Flexor Group (Median & Ulnar)
Triceps Muscle Stretch Reflex
Sensation to Middle finger
c8 neurological level
Finger Flexors
Sensation to Medial Forearm (Medial Antebrachial Cutaneous Nerve)
index and pinkey finger
C8 INNERVATES THE FINGER FLEXORS
T1 neurological level
Finger Abduction Finger Adduction Sensation to Medial Arm (Medial Brachial Cutaneous Nerve)
four articulations of the AA joint
zygapophyseal joints left and right, anterior andontoid articulates with small facet on posterior aspect of anterior arch of atlas,
posterior andontoid articulates with the transaxial ligament
what is the primary motion about the AA joint
rotation
TEST QUESTION!!!!!!!! what protects from posteriolaterial disc herniation
joints of luschka
how do the facets of c2-c7 face?
oblique BUM backward upward and medial at an angle of 45 degrees
c2-c7 motion
mostly flexion and extension and coupled side bending rotation
trigger point on sternal body of sternocleidomastoid
pain around the eyes on top of the head behind the ear
trigger point on clavicular body of sternocleidomastod
pain on temporal forehead and on ear/behind ear
trigger point on digastric muscle
pain under mandible and behind ear
trapezius trigger point
pain radiating up trapezius and posterior aspect of neck and jaw
splenius cervicus trgger point
pain over posrterio aspect of neck and in front of eyes
occipitalis trigger point
pain over eyes and top/back of head
omohymoid trigger point
pain over anterior aspect of neck
platysma trigger point
pain of inferior lateral aspect of face over the jaw
semisplinalis cervisis trigger point
pain over back of head
splenius capitas trigger point
pain on top of head
subocciptus trigger point
pain in lateral band across side of head
lavator scap trigger point
pain over shoulder and scapula
what limits excessive flexion and extension of atlanto-occipital articulation (about 30°)
Atlanto-occipital membrane
what permit the atlas to rotate around the odontoid process
A tear in this ligament has the same effect as a fractured odontoid process
transverse ligament
what resist hyperflexion, ossification of this ligament can cause cervical myelopathy
Posterior longitudinal ligament (PLL):
what resist hyperextension
Anterior longitudinal ligament (ALL)
thickening can cause spinal stenosis what ligament
ligamentum flavum
C7 to sacrum, above C7: ligament nuchae
Supraspinous ligament:
anterior tender points of the cervical spine
AC1: Posterior edge of the ramus of the mandible
AC2-6: Anterior aspect of the transverse processes
AC7: Between the two heads of SCM
AC8: Medial aspect of the clavicular head
treatment position for anterior tender points
AC2-6:
AC 7:
AC8:
AC2-6: Flex, Sidebend away, Rotate away (FSARA)
AC 7: Flex, Sidebend towards, Rotate away (FSTRA)
AC8: Flex, Sidebend away, Rotate away (FSARA)
what is a risk factor for ischemic stroke and silent brain lesions on MRI, particularly in women with frequent attacks
Migrane with aura but not migrane without aura
red flags for headache?
"Worst" headache ever Change in regular headache pattern (location, duration, assoc sx, etc) First severe headache Subacute worsening over days or weeks Abnormal neurologic examination Fever or unexplained systemic signs Vomiting that precedes headache Pain induced by bending, lifting, cough Pain that disturbs sleep or presents immediately upon awakening Known systemic illness Onset after age 55 Pain associated with local tenderness, e.g., region of temporal artery
primary headaches list?
Tension-type headache,
Migraine
Cluster headache
Paroxysmal hemicrania
what is nociception in the head mediated by?
CN V trigeminal nerve Venous sinuses Nasal sinuses Dural structures Vasculature (MCA) Skin of face and anterior scalp Teeth Pharynx Parts of ear Jaw (except angle)
Upper cervical complex (OA, C1-C3)
Innervates
Neck
Posterior head
Posterior cranial fossa meninges
Angle of mandible
describe a somato visceral reflex in a Cervicogenic headache?
C1 and C2 rootlets irritate the trigeminal nerve CN V cuaseing perieved pain on anterior head they also irritate visceral afferents through CN VII X and IX causing nausea and vomitting
Greater and lesser occipital nerves
innervate what area of head and originate where
Originate from roots at C1-3
Innervate the posterior scalp
Occipital neuralgia: entrapment/trauma to these nerves
Suboccipital nerve (C1) innervates what
Innervates the occipitoatlantal joint
SD refers pain to occipital region
C2 Spinal nerve innervates what
Innervates AA joint and C2-3
Neuralgia: deep, dull pain that radiates from the occipital to parietal, temporal, frontal, and periorbital regions
+ Lacrimation and conjunctival injection of the eye on the affected side
Third Occipital nerve (from dorsal ramus of C3)
Innervates what
Innervates C2 and C3 joints
SD refers pain to frontotemporal and periorbital regions
where do afferent fibers from C1,C2, and C3 terminate
on the trigeminal- cervical nucleus.
what is the trigeminal cervical nucleus?
Terminals of trigeminal nerve and C1-3 ramify in a continuous column of grey matter formed by the pars caudalis of the spinal nucleus of the trigeminal nerve, and with the dorsal horns of the upper 3 cervical segments
Chronic sinusitis is associated with which nerve
CN V trigeminal nerve
shoulder abduction muscle root nerve
deltiod c5 axillary n
elbow flexion muscle root nerve
biceps/C5/6 musculocutaneous
brachioradilalis C6 radial n
wrist extensor muscle root nerve
Ext Carpi Radialis Longus c6 radial n
finger extensor muscle root nerve
extensor digitorum c7 posterior interosseos n
finger flexor muscle root nerve
Flexor pollicis, c8 Anterior Interosseous
Flexor digitorum C 8 Ulnar N
finger abduction muscle root nerve
first dorsal interosseos T1 ulnar n
abductor pollicis T1 median n
cervical radiculopathy pathology
Compression by spondylosis & disc herniation
(most common)
Infection, mass (arthritis/tumor), root avulsion, demyelination
thoracic outlet syndrome pathology
Compression of brachial plexus and/or subclavian artery/vein
cervical rib or tumor
Sensory/motor loss, congestion of upper extremity
Test: Adson’s test
Related somatic dysfunction
Clavicle, 1st rib; Anterior/middle scalene, inferior belly of omohyoid mm.
pronator syndrome pathology
Median nerve compressed between humeral and ulnar heads of pronator teres muscle
Forearm aches with repetitive forceful pronation
+/- decreased sensation at thenar eminence, numbness/tingling at radial 3.5 digits, thenar weakness
Test:
Repetitive pronation
Tinel/Phalen negative
Posterior Interosseous Nerve Syndrome path
Radial nerve compressed at “radial tunnel” from just distal to proximal radius to distal edge of supinator muscle with involvement of fascia
Deep ache at the dorsolateral proximal forearm
worse if resistance to middle finger extension
point tenderness near neck of radius (distal to radial head)
Pain only… No motor/sensory loss
Apparent weakness of digit extensors
Test:
TTP at radial neck and NOT at lateral epicondyle
Peripheral Artery Disease path
Decrease in peripheral blood flow
Causes include atherosclerosis (most common), trauma, dissection, thromboembolism, arteritis, vasculitis, radiation
Arterial stenosis or occlusion path
Pain with arm exertion, +/- dizziness/syncope
Causes include thromboembolism,
Subclavian steal syndrome
efflurage
a light stroking movement to encourage circula
petrissage
kneading of the muscles
Skin rolling
lifting the skin away from the deeper structures and rolling the skin fold along the body
Tapotement
striking with the side of the hand
MET for OA steps
Doctor is at the head of the table
Contact: Cradle the patients head in your hands, middle finger over the inferior portion of the patient’s occiput
Monitoring: in your minds eye see and feel the motion of the occipital condyles
Engage the barrier in all 3 planes: flexion and extension, side bending and rotation (opposite directions)
Instruct the patient to turn (rotate) toward the position of ease in rotation.
The motion of the eyes alone may be enough. The precision of the technique is in setting up your vectors AND having the correct patient resistance forces. Coach them.
OA HVLA steps
Doctor is at the head of the table, standing might be preferred
Contact: Dr’s 2nd MCP on the posterior or stuck occipital condyle.
Contact: Dr rests thumb over the patients zygoma, point toward the eye (pronate hand), traction slightly superior lifting the occiput off C1
Direction: Flex or extended over the 2nd MCP to the barrier
Sidebend and rotate to the barrier. Don’t overshoot the OA junction. Maintain tension and slight superior traction. Stack the barriers.
Your intention is to guide the posterior or stuck condyle anteriorly on C1.
The thrust is through the 2nd MCP with rotational emphasis. Angle is toward the ipsilateral eye.
Reassess. Always. Pops do not reign supreme.
MET AA steps
Doctor is at the head of the table - standing
Contact: place middle fingers posterior to articular pillars of C1 bilaterally, palm cupping sides of the head.
Monitoring: localize motion to C1 (45º).
Engage the rotational barrier.
Instruct the patient to turn toward the position of ease in rotation.
The motion of the eyes alone may be enough
AA HVLA steps
Doctor is at the head of the table - standing
Contact: Dr places 2nd MCP on the posterior articular pillar of C1. Thumb rests over the zygoma, the doctor’s hand direction is perpendicular to the cervical spine at C1 on C2.
Monitoring: flex the head up and maintain localization of motion at C1 (45º).
Direction: Engage the rotational barrier using both hands, ensuring the the 2nd MCP approximates and maintains tension.
Thrust: Rotational thrust through the barrier. Direction from 2nd MCP is angled to the patients nose (follow the more horizontal facet here)
Recheck!
relative contraindications for OA and AA HVLA
Elderly
Mild Osteoporosis
Osteoarthritis with moderate motion loss
Rheumatoid disease
Disc bulge and/or herniation with radicular symptoms
Atypical joint or facet due to congenital anomalies
Hypermobile state (connective tissue disorder, Ehler’s Danlos)
absolute contraindications for OA and AA HVLA
Lack of patient consent Absence of somatic dysfunction Joint instability Severe Osteoporosis Local metastasis Arthritis with spondylosis, ankylosis Severe disc symptoms with radiculopathy Osteomyelitis Congenital malformations: Chiari, dwarfism, osteogenesis Down syndrome (for AA anomaly risk) Vertebrobasilar insufficiency
which is true regarding the swing phase of gait?
The ipsilateral sacral base moves anteriorly about an oblique axis
during shoulder abduction the proximal end of the clavicle moves in which direction?
inferiorly
rib 3 is attached via the?
head to the vertebral body of t2 and t3
identditfy the axis of motion, plane of movement, and changing thoracic diameter of rib 2 during inspiration
transverse, sagital, anterioposterior
which ribs are the typical ribs
3-9
true ribs?
1-7
false ribs?
8-12
articulation of the manubrium and sternal body is approx what vertebral level
tv4 articulates with 2nd rib
rib 1-5 movement during inhalation and exhalation
inhaled anterior aspect moves superiorly posterior moves inferiorly/
exhaled anterior moves inferiorly posterior moves superior
rib 6-10 movement inhaled exhaled
inhaled lateral aspect superior exhaled lateral aspect inferiorly
ribs 11-12 movement inhaled exhaled
inhaled lateral aspect stuck posteriorly exhaled lateral aspect stuck anteriorly
MET ribs inhaled treat which rib
BITE Bottom inhaled treat bottom rib first
MET ribs exhaled treat which rib
BITE Top exhahaled treat top rib first
Inhaled ribs 1-5 met treatment?
Monitor the anterior, superior aspect of the fourth rib with right hand.
Flex patient’s head and neck until motion is palpated at rib 4.
Slightly sidebend the patient’s neck to the right until motion is palpated at rib 4.
Instruct patient to hold their breath in deep exhalation for 3-5 seconds.
While patient holds their breath, downward force is applied to rib 4.
When patient inhales, physician resists the superior motion of rib 4.
When tissues relax, re-engage the restrictive barrier by increasing flexion and sidebending to the feather edge of the new barrier.
Repeat steps 4-7 until no further change is felt.
Return patient to neutral.
Reassess
ribs 6-10 MET treatment
Monitor the lateral, superior aspect of the ninth rib with right hand.
Sidebend the patient’s head, neck, and shoulders to the right until motion is palpated at rib 9.
Flex patient’s head and neck until motion is palpated at rib 9.
Instruct patient to hold their breath in deep exhalation for 3-5 seconds
While patient holds their breath, downward force is applied to rib 9.
When patient inhales, physician resists the superior motion of rib 9.
When tissues relax, re-engage the restrictive barrier by increasing flexion and sidebending to the feather edge of the new barrier.
Repeat steps 4-7 until no further change is felt.
Return patient to neutral.
Reassess.
inhaled ribs 11-12 MET
patent prone
Diagnosis: Right Rib 12 Inhaled
Monitor over the posterior lateral aspect of rib 12 with cephalad hand.
Contact the patient’s right ASIS with caudal hand.
Simultaneously apply a posterior pressure to their ASIS (lifting their hip off the table) and an anterolateral pressure to rib 12.
Instruct patient to hold their breath in deep exhalation for 3-5 seconds.
While patient holds their breath, anterolateral force is applied to rib 12.
When tissues relax, re-engage the restrictive barrier by increasing traction on ASIS.
Repeat steps 4-6 until no further change is felt.
Return patient to neutral.
Reassess.
MET rib 1 exhaled treatment
Diagnosis: Right Rib 1 Exhaled
Place patients right forearm on their forehead.
Place cephalad hand on the patient’s right forearm.
Contact the posterior superior portion of rib 1 with caudal hand.
Instruct the patient to hold their breath in deep inhalation for 3-5 seconds.
While patient holds their breath, instruct them to flex their head and neck into an isometric counterforce applied with cephalad hand.
Simultaneously provide inferior traction with caudal hand on rib 1.
When patient exhales, resist superior motion of rib 1.
Wait until tissues relax.
Re-engage the barrier by finding the feather edge of the new barrier with caudal hand on rib 1.
Repeat steps 4-9 until no further change is noted.
Return patient to neutral.
Reassess.
MET exhaled rib 2
Turn the patients head 45 degrees to the left.
Place ipsilateral forearm on the rigth side of their forehead.
Place cephalad hand on the patient’s right hand.
Contact the superior posterior rib 2 with caudal hand.
Instruct the patient to hold their breath in deep inhalation for 3-5 seconds.
While patient holds their breath, instruct them to flex their head and neck into an isometric counterforce applied with cephalad hand.
Simultaneously provide inferior traction with caudal hand on rib 2.
When patient exhales, resist superior motion of rib 2.
Wait until tissues relax.
Re-engage the barrier by finding the feather edge of the new barrier with caudal hand on rib 2.
Repeat steps 5-10 until no further change is noted.
Return patient to neutral.
Reassess.
MET exhaled ribs 3-5
Contact the patients right elbow with cephalad hand.
Monitor the superior posterior rib 3 on the right with caudal hand.
Abduct the right arm until the feather edge of the barrier is engaged at rib 3.
Instruct the patient to hold their breath in deep inhalation for 3-5 seconds.
While patient holds their breath, instruct them to bring there right elbow towards their left hip while isometric counterforce is applied with cephalad hand.
Simultaneously provide inferior traction with caudal hand on rib 3.
When patient exhales, resist superior motion of rib 3.
Wait until tissues relax.
Re-engage the barrier by finding the feather edge of the new barrier by increasing abduction of right arm and inferior traction on rib 3.
Repeat steps 4-9 until no further change is noted.
Return patient to neutral.
Reassess.
MET exhaled ribs 6-10
Contact the patient’s right forearm with cephalad hand.
Monitor the superior, posterior aspect of rib 6 on the right with caudal hand.
Abduct the right arm until the feather edge of the barrier is engaged at rib 6.
Place left leg against patients right arm.
Instruct the patient to hold their breath in deep inhalation for 3-5 seconds.
While patient holds their breath, instruct them to adduct their right arm while isometric counterforce is applied with left leg.
Simultaneously provide inferior traction with caudal hand on rib 6.
When patient exhales, resist superior motion of rib 6.
Wait until tissues relax.
Re-engage the barrier by finding the feather edge of the new barrier by increasing abduction of right arm and inferior traction on rib 6.
Repeat steps 5-10 until no further change is noted.
Return patient to neutral.
Reassess.
exhaled ribs 11-12 MET
Monitor over the medial lateral aspect of rib 12 with cephalad hand.
Contact the patient’s right ASIS with caudal hand.
Induce a posterior force to their ASIS (lifting their hip off the table) while simultaneously inducing a lateral and cephalic force to rib 12.
Instruct the patient to hold their breath in deep inhalation for 3-5 seconds, and have the patient pull the ASIS anterior toward the table.
When tissues relax, re-engage the restrictive barrier by increasing traction on ASIS.
Repeat steps 3-6 until no further change is felt.
Return patient to neutral.
Reassess.
RIB HVLA set up for rib 8 ehaled
Instruct patient to cross their arms over their chest.
Roll the patient to the left and place an open, flat, left thenar eminence just superior to dysfunctional rib.
Place the patient’s elbows into your epigastrium while supporting the patient’s head with cephalad hand.
Using the patients head, introduce left sidebending until motion is palpated at rib 8.
Engage the barrier by modifying the degree of sidebending and flexion. Each time the patient exhales, take up the slack.
The final corrective force is posterior into left thenar eminence.
Return patient to neutral.
Reassess.
RIB HVLA tip
Inhaled encourage posterior aspect of rib to superiorly
Exhaled encourage posterior aspect of rib to move inferiorly
Positive seated flexion test on right means what oblique axis for sacrum
left. oblique axis is opposite seated flexion test
lymphatic perfuse all tissues except?
brain bone nonvascular structures epidermis hair nails, endomysium of muscles, maternal placenta, Inner portion of the walls of large blood vessels
why are lymphatics more permeable than blood vessels?
lack basement membrane in simple squamous empithelium
criteria for acute Low back pain?
less than 6 weeks, connective tissue healing occurs
criteria for sub acute low back pain
greater than 6 weeks less than 12
criteria fro chronic low back pain
greater than 12 weeks
what is the most comm on type of fracture in the Low back?
wedge fractures; Due to axially directed central compressive force combined with
an eccentric compressive force. A flexion bending movement occurs at the time of injury
what is spondylosis?
Degenerative changes within the intervertebral disc and adjacent vertebral bodies
what is spondylolysis
Defects usually in the pars interarticularis WITHOUT anterior displacement of the vertebral body
what is spondiloylisthesis?
Anterior displacement of one vertebrae in relation to the one below.
Usually due to factures in the pars interarticularis of the vertebrae
what is the most common cause of back pain in children less than 10
Spondylolysis and spondylolisthesis
what is the most common kind of spondylolithesis in patients less than 50
Isthmic Spondylolisthesis
what is the most common kind of spondylolithesis in patients older than 50
Degenerative Spondylolisthesis
which ligaments and what spinal segment are most prone to sprain in the spine?
posterior ligament of lumbar region
where does the counus medularus end?
L1 L2
what nerves pass through the psaos major?
lumbar plexus L1-L4
where does the sacral plexus lie?
Lies between piriformis and pelvic fascia l4-s4
Myotome of L5
Peroneal nerve • Ankle Dorsiflexion (tibialis anterior) • Ankle eversion (peroneus muscles) • Great toe extension (EHL) Tibial nerve • Ankle inversion (tibialis posterior) Superior gluteal nerve • Hip abduction (gluteus medius) • Leg internal rotation (TFL)
myotome L2-L4
Femoral nerve • Hip Flexion (iliopsoas) • Quadriceps (knee extension) Obturator nerve • Hip Adduction
Myotome S1-S2
Inferior gluteal nerve • Hip extension (glut max) Sciatic nerve • Knee flexion (hamstrings) Tibial nerve • Foot Plantar Flexion (gastroc and soleus)
which radiculopthy is responsible for foot drop and dermotomal pain pattern
L5 posteriolateral thigh heel walking dorsal foot
L4 radiculopothy dermotaomal pain pattern
anteriolateral thigh
S1 radiculopathy dermotomal pain and gait changes
toe walking posterior thigh and calk adn heel
piriformis sydrome can impinge which nerve
sciatic nerve sometimes pierces piriformis
red flags for cauda equina syndrome?
Progressive motor or sensory deficit Saddle anesthesia Bilateral sciatica or leg weakness Difficulty urinating, including retention Fecal incontinence
insertion of psoas major?
lesser trochanter of the femur
short leg discrpencies how does the lumbar spine react
rotates towards short leg sidebends away
what are the orientation of the lumbar facets?
The facets are oriented at a 90 degree angle on the transverse plane and a 45 degree angle on the coronal plane. OREINTATION OF FACETS IS WHY THERE IS MINIMAL ROTATION IN LUMBAR SPINE
the superior face of the lumbar spine faces what two direvctions?
posterior and medial (convave)
then inferior facet of the lumbar spine faces?
anteriorly and laterally (convex)
In a type II lumbar flexion how is the facet stuck and what way does the vertebrae rotate and sidebend in relations to the stuck facet joint?
Facet stuck open lumbar spine rotates and sidebends away towards closed facet
In type II lumbar extension how is the facet stuck and what way does the vertebrae rotate and sidebend in relations to the stuck facet joint?
stuck closed vertebrae rotate sidebend towards the closed facet
MET for Type I Lumbar Joint Dysfunction
Example Diagnosis: L2-4 NSLRR (apex at L3)
physician in front standing at side of table
sidebend side down (left lateral recumbantO
cephalad hand monitors apex of group curve exL3
physician lifts both feet towards cieling introducing right sidebending and slight left rotation
caudad hand resists the patient’s effort to push both feet to the floor for 3-5 seconds.
relax engage new barrier
repeat recheck
.
MET for Type II Lumbar Joint Dysfunctions
Example Diagnosis: L3 ERSL
Physician front of table side of patient
Patient posterior TP down EX left side down)
caudad hand monitors L3 as cephald hand flexes trunk until motion at t3
cephalad hand monitors L4 as caudad flexes lower extremities until motion at L4
introduce right rotation by pushing right shoulder posteriorly while monitoring l3-l4
with caudad hand physician right side bends by lifting feet to the cieling
caudad hand resisit patient effort to pull feet to floor 3-5 seceond engage barrier repeat recheck
HVLA type 1 lumbar spine
Example DX: L2-4 NSrRl (Apex at L3)
physician in front at side of patient
posterior TP down (left recumbent) shoulders and knees perpendicular)
cephalad hand monitors apex of group curve L3
flexes and extends until point of maximum ease
felx patients right knee forward foot in popliteal space of left knee
phycisian pulls left elbow anteriorly to introduce right rotation and left sidebending
engage the barrier fully at the end of ehalation provide corrective thrust
HVLA type II lumbar
Example Diagnosis: L3 ERSL
physician front and side of table
TP down
flexes until motion at t3
motiors L4 flexes lE
right knee forwards so right foot in left popliteal space
physician forearm to peck to introduce right rotation
Physcian contacts right buttock introducing anterior roation of pelvis
corrective force upon exhaling
Al1 tender point location and teatment
Medial to the anterior superior Iliac spine (ASIS)
F St RA knees towards rotates away
AL2 TP location and treatment
Medial to the anterior inferior iliac spine (AIIS)
F Sa RT knees away rotates towards
AL3 TP location and treatment
Lateral to the anterior inferior iliac spine (AIIS)
F Sa RT knees away rotates towards
AL4 TP location and treatment
Inferior to the anterior inferior iliac spine (AIIS)
F Sa RT knees away rotates towards
AL5 TP location and treatment
Anterior, superior aspect of the pubic ramus just lateral to the symphysis
F Sa RA knees towards rotates away
PL1-PL5 spinous process TP location and treatment
On the inferolateral aspect/tip of the deviated spinous process of the dysfunctional segment.
*Vertebral rotation is opposite the side of spinous process deviation.
e-E Sa Ra
-Patient prone: Extend to spinal level by lifting extremity or ASIS on side of tender point, which also rotates pelvis/lower segment toward and upper segment away; side bend away (adduct lower extremity
PL1-PL5 transverse process TP location and treatment
e-E SA RA (upper segant rotated away
On the posterolateral aspect of the transverse process of the dysfunctional segment.
-Patient prone: Extend to spinal level by lifting extremity or ASIS on side of tender point, which also rotates pelvis/lower segment toward and upper segment away; side bend away (adduct lower extremity
facet orientation in c spine
superior facet BUM 45 degrees oblique plane
how do you conduct the vertebral artery insufficiency test?
extend rotate test side opposite rotation
