Exam 1 Flashcards
Somatic Dysfunction
Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, myofascial
Disease is
the result of anatomical abnormalities followed by physiological discord
Who exploded the pseudomotor (ANS) impact of somatic dysfunction
Irvin Korr
Acute somatic dysfunction
Immediate or short term impairment or altered function of related components of the somatic (body framework) system
Characterized by: vasodiliation edema tenderness pain tissue contraction
Chronic somatic dysfunction
impairment or altered function of related components of the somatic (body framework) system
Characterized by: tenderness itching fibrosis paresthesias tissue contraction
Bog/ Bogginess
Wet, spongy ground
To sink in as if in a bog
Tissue texture abnormality characterized by a palpable sense of sponginess in the tissue, interpreted as resulting from congestion due to increased fluid content
Tone
Normal feel of muscle in the relaxed state
Hypertonicity
extreme= spastic paralysis
Hypotonicity
flaccid paralysis when no tone at all
Contraction
normal tone of a muscle when it shortens or is activated against resistance
Contracture
abnormal shortening of a muscle due to fibrosis.
Most often in the tissue itself, often result of chronic condition.
Muscle no longer able to reach its full normal length
Spasm
Abnormal contraction maintained beyond physiologic need. Most often sudden and involuntary muscular contraction that results in abnormal motion and is usually accompanied by pain and restriction of normal function
Ropiness
hard, firm, rope-like
chronic condition
Elastic barrier
the range between physiologic and anatomic barrier of motion in which passive stretching occurs before tissue disruption; aka the area that warms up with stretching
Restrictive barrier
a functional limit that abnormally diminishes the normal physiologic range
Barrier “end feel”
placatory experience or perceived quality of motion when a joint is moved to its limit- a barrier is approached normal end feel
bone to bone (elbow)
Soft tissue approx (knee flex0
Tissue stretch (ankle dorsiflex)
Examples of Restricted ROM and abnormal end feel
early muscle spasm
late muscle spasm
hard capsular
soft capsular
early muscle spasm
protective spasm after injury
late muscle spasm
chronic spasm, think chronic tissue change
hard capsular
frozen shoulder
soft capsular
synovitis (swelling of knee after injury
Tenderpoints
small discrete hypersensitive areas within myofascial structures that result in localized pain
Trigger point
small discrete hypersensitive areas within myofascial structures- palpation causes referred pain away from site
According to Osteopathic practices and principles which of the following do we treat?
a. symptoms
b. illness
c. pain
d. psychosocial causes of disease
e. the patient
e. the patient
A 22 A 22-yo female c/o rt. ankle pain after “twisting” her ankle playing tennis yesterday. Passive motion testing reflects diminished dorsiflexion with an empty end-feel. Which barrier description is associated with this finding?
a. bony
b. ligamentous
c. tissue approximation
d. tendinous
e. guarding
e. guarding
patient resists touching end point
ROM Planes
Sagittal
-flexion/ extension
Frontal (coronal)
-sidebending
Horizontal (transverse)
-rotation
fibrous joint
skull articulations
cartilaginous joint
discs between vertebrae
Synovial
6 types
extremities
End Feel of range of motion
5
elastic abrupt hard empty crisp
elastic end feel
like a rubber band
abrupt end feel
osteoarthritis or hinge joint
hard end feel
somatic dysfunction
empty end feel
stops due to guarding
Crisp end feel
involuntary muscle guarding as a pinched nerve
Static
maximal ROM a joint can achieve with an externally applied force
Dynamic
ROM an athlete can produce and speed at which he/she can produce it
Functional unit
two vertebrae, their associated disc, neuromuscular, and other soft tissues
coupled motion
consistent association of a motion along or about one axis, with another motion about or along a second axis. the principle motion cannot be produced without the associated motion occurring as well
Linkage
by linking multiple structures together you will get increased ROM
Four natural curves of the spine
Cervical: lordosis
Thoracic: kyphosis
Lumbar: lordosis
Sacral: kyphosis
First woman DO
Jeanette Bowles
What happened in 1910 that changed the face of medical education for MDs and DOs?
Abraham Flexner produced the Flexner report with harsh criticism of medical education in the US.
Founder of osteopathy
AT Still
3 of AT Stills children die
1864
Day AT Still flung the banner of osteopathy
June 22, 1874
First school of osteopathy opened
1892
KCU established
1916
Spanish flu
1917-1918
DOs could serve in the military
1957
California referendum (DOs can turn tin degrees for MD degrees)
1961-1974
Four Tenets of osteopathic medicine
Four Tenets of Osteopathic Medicine
- The mind, body & spirit are a unit.
- The body is capable of self- regulation, self-healing, and health maintenance.
- Structure and function are reciprocally interrelated.
- Rational treatment is based upon understanding & implementing the other 3 tenets.
Acute
- vascular
- sympathetic
- musculature
V: inflamed vessel wall injury, endogenous peptide release
S: local vasoconstriction overpowered by local chemical release, net effect is vasodilation
M: local increase in tone, muscle contraction, spasm- mediated by increase spindle activity
Chronic
- vascular
- sympathetic
- musculature
V: sympathetic tone increases vascular constriction
S: vasoconstriction, hypersympathetic tone, may be regional
M: decreased muscle tone, flaccid, mushy, limited ROM due to contracture
Acute
- Pain
- Visceral Fxn
- Visceral Dysfunction
P: sharp, severe, cutting
VF: minimal somatoviseral effects
VD: may or may no be present; if trauma is severe it is often present
Chronic
- pain
- Visceral Fxn
- Visceral Dysfunction
P: Dull, ache, paraesthesias (tingling, burning gnawing, itching)
VF: somatovisceral effects common
VD: often involved in somatic dysfunction
Acute
- TTA
- Asymmetry
- Restriction
- Tenderness
T: Red, swollen, boggy, increased tone
A: present
R: Present, painful w/ motion
T: Sharp pain
Chronic
- TTA
- Asymmetry
- Restriction
- Tenderness
T: Dry, cool, ropy, pale, decreased tone
A: present, compensation occurs
R: present, maybe not guarded
T: dull, achy pain
Temperature receptors
Deep in the hand
Dorsal back of hand has thinner skin, better for temp palpation
Touch receptors
Concentrated in the pads of the fingers (not the tips)
Sagittal
Front and back bending
Flex leg at hip, Leg extension
Frontal (coronal
Side bending
Shoulder abduction, shoulder adduction (not horizontal)
Transverse
Head rotation
Horizontal adduction
Horizontal abduction
Fascial Anatomy
These connective tissue layers are composed of collagen fibers (and occasionally also elastin fibers) in an amorphous matrix of hydrated proteoglycans which mechanically links the collagen fiber networks in these structures
Fascia is
a complete system with blood supply, fluid drainage & innervations
-largest organ system in the body
Fascia is composed of
irregularly arranged fibrous elements of varying density
Fascia function
involved in tissue protection & healing of surrounding systems
Fascia is not:
tendons
ligaments
aponeuroses
Omnipresent
it belts each muscle, vein, n nerve and all the organs of the body
There is myofascialarthrodial continuity throughout the body
Continuity of Fascia
Perimysium (Fascia) –> Peritendium –> periosteum
Pannicular Fascia
Outermost layer of fascia derived from somatic mesenchyme & surrounds entire body with exception of the orifieces; outer layer is adipose tissue & inner layer is membranous & adherent, generally to the outer portion
Axial & Appendicular Fascia
aka investing layer
Internal to the pannicular layer; fused to the panniculus and surrounds all of the muscles, the periosteum of bone & peritendon of tendons
Fascia Layers
Pannicular Fascia
Axial & Appendicular Fascia
Meningeal Fascia
Visceral Fascia
Meningeal Fascia
Surrounds the nervous system, includes the dura
Visceral Fascia
Surrounds the body cavities (pleural, pericardial, and peritoneum)
Fascia FXN
Omnipotent
Provides for mobility and stability of the musculoskeletal system
1) elastic as well as contractile
2) supports and stabilizes, helping to maintain balance
3) it assists in the production and control of motion and the interrelation of motion of related parts
4) Many of the body’s fascial specializations have postural functions in which stress bands can be demonstrated
Contractile
Myofibroblasts
Healing
Macrophages
Mast cells
Percentages
Approximately 20% of cutaneous high-threshold mechanoreceptors supplying the skin also have receptive fields in the subcutaneous tissue… the loose fascia
Stretch receptors for muscles & proprioception (balance)
- only 25% in the muscle
- 75% consists of free endings in fascia
80% of the C fibers are polymodal
Liquid crystal-like properties
-Piezoelectricity
Viscoelastic material
any material that deforms according to rate of loading and deformity
Stress
is the force that attempts to deform a connective tissue structure
Strain
is the percentage of deformation of a CT
stress-strain curve can
shift with loading of tendon
During cyclic loading of tendon, the stress- strain curve gradually shifts to the right
Hysteresis
The difference between the loading and unloading characteristics represents energy that is lost in the connective tissue system; this energy loss is termed hystereresis
Creep
Connective tissue under a sustained, constant load (below failure threshold) will elongate (deform) in response to the load
Bind
a palpable restriction of connective tissue mobility
Fascial Sweater
Fascial restrictions in one area of the body, will create connective tissue restrictions (pulls) at a distance away from the site of the initial restriction. The result is abnormal myofascial & joint mobility
Newton’s Third Law
When two bodies interact, the force exerted by one is equal in magnitude and opposite in direction to the forces exerted by the other
Hooke’s Law
The strain (deformation) placed on an elastic body is in proportion to the stress (force) placed upon it.
Wolff’s Law
Bone will develop according to the under stresses placed upon it
This concept extends to fascia too
Somatic dysfunction includes
impaired or altered function of:
- skeletal
- arthroidal
- myofascial structures
- related vascular
- lymphatics
- neural element
Sherrington’s law
When a muscle receives a nerve impulse to contract, its antagonists, receive, simultaneously, an impulse to relax
Transition Zones of the Spine
Zone 1: OA, C1, C2
Zone 2: C7, T1
Zone 3: T12, L1
Zone 4: L5, Sacrum
Soft Tissue Technique Defined
A system of diagnosis and treatment directed toward tissues other than skeletal or arthrodial elements
ST Indictations & Treatment Goals
T Goal: stretch and increase the elasticity of shortened myofascial structures to return symmetry and to improve local tissue nutrition, oxygenation and removal of metabolic wastes to normalize tissue texture
A Goal: return symmetry & normalize tone
R Goal: Set the fascia free to normalize ROM
T Goal: Normalize neurologic activity (pain, guarding & proprioception) and Improve abnormal somato-somatic and somato-visceral reflexes
ST Indications
Diagnostically
- to identify areas of restricted motion, tissue texture changes, and sensitivity
Feedback about tissue response to OMT
Improve local and systemic immune response
Provide a general state of relaxation
Enhance circulation to local myofascial structures
Provide a general state of tonic stimulation
ST Relative Contraindictions
Individual techniques may be contraindicated in specific situations such as:
Severe osteoporosis
Acute Injuries
ST Relative Contraindictions
-severe osteoporosis
-prone pressure techniques may be contraindicated in the the thoracocostal region, but lateral recumbent techniques could be easily applied
ST Relative Contraindictions
-Acute Injuries
Direct techniques that stretch acutely injured muscles, tendons, ligaments or joint capsules may do additional damage to these structures, or increase the amount of pain the patient experiences and are therefore contraindicated
ST Absolute Contraindications
1) Fracture of dislocation
2) Neurologic entrapment syndromes
3) Serious vascular compromise
4) Local malignancy
5) Local infection (cellulitis abscess, septic arthritis, osteomyelitis
6) Bleeding disorders
Principles of ST Technique
1) patient comfort
2) Physician comfort
- to minimize energy expenditure
3) Initially, the applied forces are very gentle and of low amplitude. The force is applied rhythmically, typically 1 or 2 seconds of stretch followed by a similar time frame releasing that stretch
4) As the soft tissues are palpated responding to the technique, the applied forces can be increased to increase the amplitude of the technique. The rate of application typically remains the same
5) The applied forces should be comfortable for the patient. Some patients experience some discomfort, but it is recognized by the patient as a good discomfort
6) DO NOT allow your hands to create friction by sliding across or rubbing the skin. The physician’s hand should carry the skin and subcutaneous tissues in applying the activating force
7) The technique is continued until the desired effect is achieved. This typically means that the amplitude of excursion of the soft tissue has reached a maximum and has plateaued at that level
Stretch
Parallel traction
Increase distance between origin and insertion (parallel with muscle fibers)’
Taffy pull
Knead
perpendicular traction
Repetitive pushing of tissue perpendicular to muscle fibers
Bowstring
Inhibition
Push and hold perpendicular to the fibers at the musculotendinous part of hypertonic muscle
hold until relaxation of tissue
MFR defined
A system of diagnosis and treatment first described by AT. Still and his early students, which engages continual placatory feedback to achieve release of myofacial tissue
INR (integrated neuromuscuoloskeletal release)
A treatment system in which combined procedures are designed to stretch & reflexively release patterned soft tissue & joint related restrictions
INR techniques
Breath holding
Prone/Supine simulated swimming & pendulum arm swing maneuvers
R/L Cervical rotation
Isometric limb & neck movements against the table
Patient evoked movement from cranial nerves (eye, tongue, jaw)
Indications for MFR
Somatic dysfunction
-Almost all soft tissue or joint restriction
When HVLA (high velocity low amplitude) or Muscle energy is contraindicated -consider indirect MFR
When counterstain may be difficult secondary to a patient’s inability to relax
Contraindications of MFR
Absolute
Lack of patient consent
Absence of Somatic Dysfunction
Contraindications of MFR
Relative
1) Infection of soft tissue or bone
2) Fracture, Avulson, or dislocation
3) Metastatic disease
4) Soft tissue injuries: thermal, hematoma, or open wounds
5) Post-op patient with wound dehiscence
6) Rheumatologic condition involving instability of cervical spine
7) DVT or Anticoagulation therapy
Activating Forces
Inherent Forces
Respiratory Cooperation
Patient Cooperation
Inherent Forces
Using the body’s PRM (primary respiratory mechanism)
Respiratory Cooperation
Refers to a physician directed, patient performed, inhalation or exhalation or a holding of the breath to assist with the manipulative intervention
Patient Cooperation
The patient is asked to move in specific directions to aid in mobilizing specific areas of restriction
MFR Treatment Endpoint
1) A three dimensional release is often palpated as:
- warmth
- softening
- increased compliance/ROM
2) The continuous application of activating forces no longer produce change
3) When finished, recheck of the tissue demonstrates symmetry
Muscular or sturdy body build
Mesomorphic
Mid-ranges of ROM
Characterized by relative prominence of structures developed from the embryonic mesdorm
Thin body build
Ectomorphic
- Long and linear frame
- Tend to have higher ROM
- Characterized by relative prominence of structure developed from embryonic ectoderm
Heavy (Fat) body build
Endomorphic
- obese, increased fatty tissue
- tend to have lower ROM
- characterized by relative prominence of structures developed from embryonic endoderm
Which body habitus is associated with an excess of mesoderm
Mesomorph
Yellow skin color
Jaundice
Live disease
Redness skin color
Erythema
Inflammation
Blue skin color
Cyanosis
- Reynaud’s disease
- Children with Tetralogy of Fallot exhibit bluish skin during episodes of crying or feeding
Blackness skin color
Necrosis
Pale skin color
May indicate anemia
Spanish Flu
1917-1919
1 in 4 persons in US became ill with the flue
- increased susceptibility to pneumonia
-1 in 4 soldiers died
-500,000 deaths
-osteopathic physicians reported only 160 deaths during the period (just 10 attributed to pneumonia)
-Based on extrapolation of the mortality only 73,500 deaths from DOs
11,118 influence cases, 513 pneumonia
- osteopathic care= 0.486%
- medial/osteopath= 1.08 death rate
Lymph
clear yellow fluid composed of proteins, salts, fats, lymphocytes, clotting factors, bacteria and viruses
Lymphatic Development
Begins during 5th week of gestation
Develops from the mesdoerm
Immature at birth
-lymphoid tissue increases until puberty to mature, but lymphoid tissue regresses
Liver
Gate keeper of hepatic-biliary pancreatic venous and lymphatic drainage
Pressure sensitive organ
1/2 of the bodies lymph is found here
Clears bacteria
Lymphatic Channels perfuse what?
Perfuse all tissues of the body except
- epidermis
- endomysium
- bone marrow
- select portions of peripheral nerves
Lymphatic Vessels
1) Composed of endothelium that lacks a basement membrane
- which allows fluid, protein, bacteria, cellular debris, emulsified fats, to readily enter
2) superficial or deep
3) One way lymphatic valves ensure unidirectional flow
4) Superficial lymphatic vessels typically follow the course of the veins
5) Deep lymphatic vessels typically follow the course of the being but may be compressed by arterial pulsations
6) Larger vessels have smooth muscle
- under sympathetic control (fight or flight vs rest & digest)
- increase sympathetic tone
- decrease peristalsis
- increases congestion
7) Small vessel distension –> activation of endothelial cell contractile fibers
Thoracic Duct
1) Drain the majority of the body
2) Empties into the venous system at the junction of the
- left internal jugular vein
- left subclavian vein
3) Cisterna Chyli
- Dilated collecting sac in the abdomen where the lymphatic trunks draining the lower half of the body merge
- Ascends from the collecting sac as the thoracic duct into the thorax
Right Lymphatic Duct
Drains
- right side of the head, neck and thorax
- right upper limb
Empties into the venous system at the junction of the
- right internal jugular vein
- right subclavian vein
You are doing a technique in a certain area, where would it drain to (thorax or right)
35-60% of the drainage through the thoracic duct is associated with
respiration
Mechanisms of Flow
Interstitial Fluid Pressure
- Increased by
1) increased arterial pressure
2) increased capillary permeability
3) decreased oncotic pressure
4) increased interstitial fluid protein
Lymphatic pumps
1) intrinsic pump –> pressure gradients
- large vessel distension= smooth muscle contraction
- small vessel distension= activation of endothelial cell contractile fibers
2) Extrinsic pump= direct pressure on lymphatic vessels
- thoracic diaphragm
- pelvic diaphragm
Thoracic Duct
The major lymphatic vessel of the body, which drains lymph from the entire body except the upper right quadrant and returns it to the venous system via the thoracic inlet
Thoracic inlet
junction of the thoracic duct with the venous system
Thoracic outler
Thoracic outlet syndrome= compression of the arteries, veins and/or nerves of the upper extremities by the clavicle, first rib or scalene muscles (covered later in the curriculum)
Sibson’s Fascia
Suprapleural membrane
The thoracic duct travels cephalic through Sibson’s fascia to the level of C7 then U-turns to the thoracic inlet
Lymphatic Treatment: Indications
1) acute somatic dysfunction
2) sprains (ligament), strain (muscle or tendon)
3) Edema, tissue congestion or lymphatic / venous stasis
- Mild CHF
- COPD
- Asthma
4) Pregancy
5) Certain infections
6) Inflammation
7) Pathologies with significant venous &/or lymphatic congestion
Lymphatics: Contraindications
Relative
1) Cancer
2) Certain Infections, caution with:
- Overwhelming bacterial infections
- Risk of dissemination (abscess, osteomyelitis)
- Chronic infections with risk of reactivation
- Consider use of antibiotics first to reduce chance of septic spread
3) Circulatory Disorders
- venous obstruction
- embolism
- hemorrhage
4) Coagulopathies
- Anticoagulants
5) Osseous fracture, dislocation or osteoporosis
Lymphatics: Contraindications
Absolute
1) Anuria- failure of the kidneys to produce urine
- if the patient is not on dialysis
- the kidneys must be functional to process the extra fluid
2) Necrotizing fasciitis in the treatment area
3) Patient unable to tolerate the treatment
4) Patient does not desire treatment
Principles of Diagnosis
1) Indications and risk-to-benefit ratio
2) Central myofascial pathways
3) Fluid pumps
4) Spinal involvement
5) Peripheral/ regional pathways
Principles of Diagnosis
1) Indications and risk to benefit ratio
History & physical exam- swelling, shortness of breath, areas of puffiness, bogginess infection or tissue trauma
Is lymphatic treatment indicated
Does the patient have any contraindications
Principles of Diagnosis
2) Central myofascial pathways
Assess transition zones for compensated and uncompensated fascial patterns
Principles of Diagnosis
3) Fluid pumps
Assess muscular and fascial diaphragmatic functions that may limit lymphatic flow
Principles of Diagnosis
4) Spinal involvement
After treatment of the central pathways and diaphragms other somatic dysfunction that interferes with respiration should be assessed
-Thoracic, rib, sternal dysfunction, cranial base, C3-5
Principles of Diagnosis
5) Peripheral/ Regional Pathways
Evaluation of terminal lymphatic drainage sites +/- other local tissues for the presence of congestion and excess fluid in the interstitium
Principles of Lymphatic Treatment
1) Remove impediments to lymphatic flow
2) Enhance mechanisms involved in respiratory-circulatory homeostasis
3) Extrinsically augment the flow of lymph and other immune system elements
4) Further mobilize lymphatic fluids from local or regional tissues that would benefit from decongestion
Principles of Lymphatic Treatment
-Focus on
Focus on treatments that interact with lymph formation and/or flow
- improve local tissue motion to enhance lymph formation
- reduce myofascial restriction to improve lymphatic flow
- creation of external forces to act as extrinsic pumps for lymphatic fluid mobilization
- Enhance of respiratory mechanisms to maximize venous and lymphatic return
Treatment Technique Order
Lymphatics
Goal 1
-Open myofascial pathways at transition areas of the body
Goal 2
-Maximize normal diaphragmatic motions
Goal 3
- Increase pressure differentials or transmit motion to pump or augment fluid flow beyond normal levels
Goal 4
-Mobilize targeted tissue fluids into the lymphaticovenous system
Muscle Energy is
Voluntary contraction of patients muscle
- in a precisely controlled direction
- varying levels of intensity
- Against a distinctly executed counter source
Active technique
-patient contributes the corrective force
Direct technique
-positioned to the restrictive barrier
Patients motion is away from barrier
Isometric contraction
Contraction of a muscle with no change in distance between the origin and insertion
Concentric isotonic contraction
Contraction of a muscle with approximation of origin and insertion
Eccentric isotonic contraction
Contraction of a muscle with separation of origin and insertion
Isolytic contraction
Non-physiologic
Attempted concentric contractions with an external force causing separation of origin and insertion
Isometric vs Isotonic
Isometric
1) careful positioining
2) light to moderate contraction
3) unyielding counterforce
4) relaxation after contraction
5) repositioning
Isotonic
1) careful positioning
2) hard to maximize contraction
3) counterforce permits controlled motion
4) relaxation after contraction
5) repositioning
Muscle Energy -Indications
Muscle energy techniques are used to
1) balance muscle tone
2) strengthen reflexively weakened musculature
3) improve symmetry of articular motion
4) enhance the circulation of body fluids (blood, lymph)
5) length a shortened, contractured, or spastic muscle group
Versatile to use in combination with other osteopathic manipulative techniques
Muscle energy- sequence of Technique
1) The physician positions the body part to be treated, at the position of initial resistance
2) The patient is instructed in the intensity, duration and direction of the muscle contraction
3) The physician directs the patient to contract the appropriate muscle(s) or muscle group
4) The physician uses counterforce in opposition to and equal to patients muscle contraction
5) The physician maintains forces until an appropriate patient contraction is perceived at the critical articulation or area (3-5 sec)
6) The patient is directed to relax while the physician simultaneously matches the decrease in patient force
7) The physician allows the patient to relax and sense the tissue relaxation with his or her own proprioceptors
8) The physician takes up the slack permitted by the procedure. The slack is allowed by the decreased tension in the tight muscle, allowing it to be passively lengthened
9) Step 1-8 repeat 3-5 times until the best possible increase in motion is obtained
10) The physician reevaluates the original dysfunction
Factors Influencing Successful Muscle Energy-Patient
1) Contract too hard
2) Contract in the wrong
direction
3) Sustain the contraction for too short a time
4) Do not relax appropriately
following contraction
Factors influencing Successful Muscle Energy- Operator
1) Not controlling the joint
position in relation to the
barrier movement
2) Not providing the counterforce
in the correct direction
3) Not giving accurate
instructions
4) Moving to a new joint position
too soon after the patient stops
contracting
Muscle Energy- Contraindiciations
1) Local fracture
2) Local dislocation
3) Moderate‐to‐severe segmental instability in the cervical spine
4) Evocation of neurologic symptoms or signs on rotation of the neck.
5) Low vitality
6) Situations that could be worsened by muscle activity
- Post‐surgical patient ‐ internal bleeding may be caused
- Immediately following myocardial infarction
- Recent eye‐surgery – use of Oculocephalogyric reflex
7) Unable/unwilling to follow verbal commands
8) Muscle energy has been shown to cause
- Tendon avulsion (with inappropriate force in an 85 year old man)
- Rib fracture (in a patient with osteoporosis)
- Anterior chamber intraocular hemorrhage (in a patient just post cataract removal and lens implant surgery)
Articulatory Approach description
Springing techniques
Low velocity/ high amplitude
Direct techniques
Articulatory Approach
1) Gentle and repetitive motions through the restrictive barrier to restore physiologic motion
2) Applicable with the restrictive barrier is in the joint or periarticular tissues
3) Can be applied to vertebral as well as extremity somatic
dysfunction
4) May be used ona single joint, or an entire region
Articulatory Technique Indications
Well tolerated by 1) Arthritic patients 2) Elderly or frail 3) Critically ill or post‐operative patients 4) Infants or very young patients 5) Patients unable to cooperate with instructions
Steps of Articulatory Technique
- The physician should also be in a position of comfort.
- The physician moves the affected joint or body part until the restrictive barrier is engaged.
- A gentle but firm force is applied carrying the body part a short distance through the restrictive barrier.
- This force is applied rhythmically, typically 1 or 2 seconds of stretch followed by a similar time frame releasing that stretch. The joint is permitted to return to a point
just short of its restrictive barrier - As the patient responds to the technique, the restrictive barrier will shift position
within the physiologic range of motion. For each cycle of the applied technique, reengage the restrictive barrier and carry the affected body part a short distance further through that new barrier to normal motion. - The applied forces should be comfortable for the patient. Some patients experience
some discomfort, but it is recognized by the patient as a “good discomfort.” - The technique is continued until the location of the restrictive barrier reaches a
plateau; that is, no further increase in range of motion can be achieved by
continuing the technique, or until full physiologic range of motion has been
restored to the joint(s) being treated.
Articulatory Technique – Contraindications
Relative
Relative
- Vertebral artery compromise
( Avoid combination of rotation and extension in the cervical spine)
Articulatory Technique – Contraindications
Absolute
1) Local fracture or dislocation 2) Neurologic entrapment syndromes 3) Serious vascular compromise 4) Local malignancy 5) Local infection (e.g., cellulitis, abscess, septic arthritis, osteomyelitis) 6) Bleeding disorders
Muscle Energy Technique vs Articular Technique
Muscle Energy Technique
-Direct Technique
- Activating force: Patient muscle contraction 3‐5 times, 3‐5 seconds
- Patient Cooperation: Required (Active Technique)
- Goal: Alleviate Somatic
Dysfunction
Articular Technique - Direct Technique - Activating Force: Repetitive physician directed motions - Patient Cooperation: Relaxation (Passive Technique) - Goal: Alleviate Somatic Dysfunction
