Exam 2 Flashcards
1
Q
For ANY disease state, the patient must be STABLE before performing OMT
A
Cardiovascular, pulmonary, GI, GU, etc.
The sicker/weaker/more injured a patient is, use gentler techniques
New onset of chest pain or shortness of breath is not a time for OMT!
2
Q
Somatic dysfunction can occur anywhere in the body at
A
Sympathetics levels
Paraysmpathetic levels
Soma (not autonomic related)
3
Q
Viscerosomatic reflexes occur at
A
Sympathetics levels
Parasympathetics levels
4
Q
Facilitated segments ONLY occur at
A
Sympathetics
5
Q
If someone has a nocturnal cough at night, a couple things to think about is it may be due to asthma (pulmonary issue) or reflux (GI issue) for example. Where you find somatic dysfunction may be a clue to which one it is and what medication may be helpful.
For example, if it is found at T2 you would think more ___
For example, if it is found at T8 you would think ___
For example if it is found at T5 that could be ___
A
more pulmonary issue and maybe albuterol might be answer choice
think this is more GI and maybe omeprazole might be answer choice
be either pulmonary or GI and you would need more information to get correct answer
6
Q
Important to treat the thoracoabdominal diaphragm if flattened (indicates diminished zone of apposition). People with COPD are an example of people with a flattened diaphragm and diminished zone of apposition.
A
Treatment improves diaphragmatic excursion which improves the pressure gradient between abdominal cavity and thoracic cavity, which helps improve lymphatic flow
Treatment improves lymphatic flow also by relaxing the tension in the thoracoabdominal diaphragm
7
Q
When treating a group dysfunction with OMT
A
Go for the apex (middle) of the group curve
8
Q
A 78-year-old-female, with a history of congestive heart failure due to hypertension, presents to the emergency department with shortness of breath and swelling in the lower extremities for the past two hours. Lung auscultation reveals rales. What is the most likely level of facilitation due to a viscerosomatic reflex in this patient? A. OA B. L2 C. T3 D. T8 E. T11
A
C
In this case even though you have both parasympathetic and sympathetic levels which would be present in this patient’s presentation, you would only chose C, because facilitation occurs only at the sympathetic level!
9
Q
A 78-year-old-female, with a history of congestive heart failure due to hypertension, presents to the emergency department with shortness of breath and swelling in the lower extremities for the past two hours. Lung auscultation reveals rales.At which level would you expect her to have somatic dysfunction due to viscero-somatic reflex relating to her presentation? A. OA B. L2 C. T3 D. T8 E. T11
A
In this case, both A and C would be correct answers, because both the parasympathetic and sympathetic nervous system would have viscerosomatic reflexes present in this patient’s clinical scenario!
10
Q
A 78-year-old-female, with a history of congestive heart failure due to hypertension, presents to the emergency department with shortness of breath and swelling in the lower extremities for the past two hours. Lung auscultation reveals rales. At which level would you expect her to have somatic dysfunction due to a sympathetic viscero-somatic reflex relating to her presentation? A. OA B. L2 C. T3 D. T8 E. T11
A
C
In this case even though you have both parasympathetic and sympathetic levels which would be present in this patient’s presentation, you would only chose C, because the question asks for the sympathetic level!
11
Q
A 78-year-old-female, with a history of congestive heart failure due to hypertension, presents to the emergency department with shortness of breath and swelling in the lower extremities for the past two hours. Lung auscultation reveals rales. At which level would you expect her to have somatic dysfunction due to a parasympathetic viscero-somatic reflex relating to her presentation? A. OA B. L2 C. T3 D. T8 E. T11
A
A
In this case even though you have both parasympathetic and sympathetic levels which would be present in this patient’s presentation, you would only chose A, because the question asks for the parasympathetic level!
12
Q
Biomechanical (structural, postural)
A
Anatomy of muscles, spine, extremities; posture, motion
OMT directed toward normalizing mechanical somatic dysfunction, structural integrity, physiological function, homeostasis
13
Q
Neurological
A
Emphasizes CNS, PNS and ANS that control, coordinate and integrate body functions
Proprioceptive and muscle imbalances, facilitation, nerve compression disorders, autonomic reflex and visceral dysfunctions, brain/CNS dysfunctions
14
Q
Respiratory/Circulatory
A
Emphasizes pulmonary, circulatory and fluid (lymphatic, CSF) systems
Lymphatic techniques
15
Q
Metabolic/Nutritional
A
Regulates through metabolic processes
16
Q
Behavioral (Psychobehavioral)
A
Focuses on mental, emotional, social and spiritual dimensions related to health and disease
17
Q
Fryette Law 1
A
When side-bending is attempted from neutral (anatomical) position, rotation of vertebral bodies follows to the opposite direction.
Typically applies to a group of vertebrae (more than two)
Occurs in a neutral spine (no extreme flexion or extension) NO SAGITTAL COMPONENT
Side-bending and rotation occur to opposite sides
Side-bending precedes rotation
Side-bending occurs towards the concavity of the curve
Rotation occurs towards the convexity of the curve
May be described as a non-traumatic injury
Diagnosed as a Type I dysfunction when somatic dysfunction present
18
Q
Fryette Law 2
A
When side-bending is attempted from non-neutral (hyperflexed or hyperextended) position, rotation must precede side-bending to the same side.
Typically applies to a single vertebra
Occurs in a non-neutral spine (flexion or extension of spine present) SAGITTAL COMPONENT
Side-bending and rotation occur to same sides
Rotation precedes side-bending
Rotation of the vertebra occurs into the concavity of the curve of the spine
May be described as traumatic injury
Diagnosed as a Type II dysfunction when somatic dysfunction present
19
Q
If INDIRECT treatment used
A
exaggerate/augment the dysfunction
Take the dysfunction the way it likes to go
20
Q
If DIRECT treatment used
A
engage the barrier/reverse the dysfunction
Take the dysfunction the way it does not like to go
21
Q
Indirect Technique
A
Somatic dysfunction is exaggerated or augmented
Somatic dysfunction is taken the way it likes to go
Restrictive barrier is disengaged
Dysfunction is taken into position of injury
Uses inherent forces
Uses a compressive, tractional, or torsional component
22
Q
Examples of Indirect Techniques
A
Counterstrain
Facilitated Positional Release (FPR)
Balanced Ligamentous Tension Technique (BLT)
Functional Technique
Myofascial Release (may also be direct)
Cranial (may also be direct)
Still Technique (combined indirect and direct)
Initial positioning of Still Technique set up is indirect
Ending positioning of Still Technique is direct
23
Q
Counterstrain: Steps of Treatment
A
Assess the “this is a 10” pain level
Maintain finger contact at all times (NOT PRESSING FIRM constantly, only monitoring!)(***continuous monitoring)
this is to monitor tension, not to treat
Find the position of comfort
Retest by pressing with contact finger
This is a passive treatment
Hold it for 90 seconds (that’s the time for ALL counterstrain points, including ribs)
monitor tension and response
Return patient to neutral position SLOWLY!!
Recheck pain level
should be a 3 or less
The only time you press firmly is when finding the point, repositioning the point. All other times you are keeping you contact finger on point to just monitor location.
24
Q
Anterior Cervical CS Points
Anterior C 1
Location
Treatment Position
A
Mandible=Posterior aspect of the ascending ramus of the mandible at the level of the earlobe
Transverse process=Lateral aspect of the transverse process of C1
RA
25
Anterior Cervical CS Points
Anterior C 2-6
Location
Treatment Position
On the anterolateral aspect of the corresponding anterior tubercle of the transverse process
FSARA
26
Anterior Cervical CS Points
Anterior C 7
Location
Treatment Position
On the clavicular attachment of the SCM
| FSTRA
27
Anterior Cervical CS Points
Anterior C 8
Location
Treatment Position
At the sternal attachment of the SCM on the medial end of the clavicle
FSARA
28
Posterior Cervical CS Points
PC1 Inion
Location
Treatment Position
On the inferior nuchal line, lateral to the inion
| Marked Flexion
29
Posterior Cervical CS Points
PC1 Occiput
Location
Treatment Position
On the inferior nuchal line at the splenius capitis (midway between the inion and mastoid)
Extended
30
Posterior Cervical CS Points
PC2 Occiput
Location
Treatment Position
On the inferior nuchal line at the attachment of semispinalis capitis
Extended
31
Posterior Cervical CS Points
PC2 Midline Spinous Process
Location
Treatment Position
On the superior aspect of the spinous process
| Extended
32
Posterior Cervical CS Points
PC3 Midline Spinous Process
Location
Treatment Position
At the side or inferolateral aspect of the spinous process of C2
FSARA
33
Posterior Cervical CS Points
PC4-PC8 Midline Spinous Process
Location
Treatment Position
On the inferior or inferolateral aspect of the tip of the spinous process. Remainder of tender points follow this pattern.
ESARA
34
Posterior Cervical CS Points
PC3-PC7 Lateral
Location
Treatment Position
On the posterolateral aspect of the articular process associated with the dysfunctional segment
ESARA
35
Tender Point Anterior
AT1
Location
Classic Treatment Position
Midline or just lateral to the jugular (suprasternal) notch
| Flexion to dysfunctional level
36
Tender Point Anterior
AT2
Location
Classic Treatment Position
Midline or just lateral to the junction of manubrium and sternum (angle of Louis)
Flexion to dysfunctional level
37
Tender Point Anterior
AT3-AT5
Location
Classic Treatment Position
Midline (or with some degree of sidedness) at level of corresponding rib
Flexion to dysfunctional level
38
Tender Point Anterior
AT6
Location
Classic Treatment Position
Midline (or with some degree of sidedness) xiphoid–sternal junction
Flexion to dysfunctional level
39
FPR
Body part in NEUTRAL position (flatten the curve/spine)
COMPRESSION applied to shorten muscle/muscle fibers (some cases may have TRACTION instead)
Place area into EASE of motion (INDIRECT) for 3-5 seconds
Return body part to neutral
THIS TECHNIQUE IS INDIRECT!!!!
40
FPR Example
| If C2 is extended, rotated right, side-bent right, you would
Place neck in a neutral position (flatten curve)
Add a compressive force
Then take C2 into extension, right rotation and right side-bending
Hold for 3-5 seconds
Return to neutral position and release compressive force
41
Still Technique
Tissue/joint placed in EASE of motion position (augments the somatic dysfunction)
Compression (or traction) vector force added
Tissue/joint moved through restriction (into and through the restrictive barrier) while maintaining compression (or traction) and force vector
THIS TECHNIQUE GOES FROM INDIRECT TO DIRECT!!!!
42
Still Technique
Tissue/joint placed in EASE of motion position (augments the somatic dysfunction)
Compression (or traction) vector force added
Tissue/joint moved through restriction (into and through the restrictive barrier) while maintaining compression (or traction) and force vector
THIS TECHNIQUE GOES FROM INDIRECT TO DIRECT!!!!
43
There are many ways to ask how to diagnose C2 and once you figure out the diagnosis you can answer the treatment questions, for example:
C2 does not translate well to the right and becomes more symmetrical in extension
C2 translates easier to the left and becomes more asymmetrical in flexion
Both of these give you the diagnosis of C2 E RR SR
44
Examples of Direct Techniques
Myofascial Release (May also be indirect)
Soft tissue
Articulatory
Muscle Energy
High velocity, low amplitude (HVLA)
Springing
Cranial (may also be indirect)
Still Technique (combined indirect and direct)
Initial positioning of Still Technique set up is indirect
Ending positioning of Still Technique is direct
45
ME Technique
| Postisometric Relaxation
Dysfunctional Structure Positioned at Feather Edge of Direct Barrier
(Positioning is in All Three [3] Planes of Motion)
Physician Continuously Monitors Dysfunction
Patient is Instructed to GENTLY Push AWAY From the Barrier
Physician Resists Patient’s Effort for 3 - 5 Seconds
Patient is Instructed to Relax
Physician Repositions Patient to Feather Edge of New Barrier
Repeat 3 - 5 Times or until Maximum Improvement
Passively Reposition to Neutral After Last Effort
Recheck Area of Dysfunction for Change
46
ME Technique
| Reciprocal Inhibition
Dysfunctional Structure Positioned at Feather Edge of Direct Barrier
(Positioning is in All Three [3] Planes of Motion)
Physician Continuously Monitors Dysfunction
Patient is Instructed to GENTLY Push TOWARD the Barrier
Physician Resists Patient’s Effort for 3 - 5 Seconds
Patient is Instructed to Relax
Physician Repositions Patient to Feather Edge of New Barrier
Repeat 3 - 5 Times or until Maximum Improvement
Passively Reposition to Neutral After Last Effort
Recheck Area of Dysfunction for Change
47
Cardiac Autonomics
Sympathetics:
When considering arrhythmia:
Heart: T1-6 with synapses in upper thoracic and cervical chain ganglia.
Right and left-sided distributions
Right- sinoatrial (SA) node and right deep cardiac plexus– predisposes to supraventricular tachyarrhythmias.
Left-atrioventricular (AV) node and left deep cardiac plexus- predisposes to ectopic PVCs and V fib and V tach
Asymmetries in sympathetic tone may play a role in the generation of serious arrhythmias.
48
Sympathetic Effects: Cardiac
```
Increases contractility
Increases force of contractility
Increases conduction velocity
Increases vasoconstriction
Increases peripheral vascular resistance
Increases arrhythmias (tachy-arrhythmias)
Decreases lymphatic drainage
Decreases development of collateral circulation
```
49
Peripheral Sympathetic Supply
In addition to the direct effects on the organs, the sympathetic innervation also controls the vascular tone.
Sympathetic Supply to Upper Extremity Vasculature:
Sympathetic Supply to Lower Extremity Vasculature:
T2 to T8 levels
T11 to L2 levels
50
Chapman Reflex Points
Myocardium, Thyroid, Esophagus, Bronchus
Anterior:
Posterior:
Anterior: 2nd intercostal space near sternum
Posterior: Midway between the spinous process and tips of the transverse process at T2
51
Chapman Reflex Points
Upper Lung
Anterior:
Posterior:
Anterior: 3rd intercostal space near sternum
Posterior: Midway between the spinous processes and tips of the transverse processes of T3 and T4
52
Chapman Reflex Points
Lower Lung
Anterior:
Posterior:
Anterior: 4th intercostal space near sternum
Posterior: Midway between the spinous processes and tips of the transverse processes of T4 and T5
53
Chapman Reflex Points
Liver
Anterior:
Anterior: 5th intercostal space near sternum on R
54
Chapman Reflex Points
Stomach (Acid)
Anterior:
Anterior: 5th intercostal space near sternum on L
Stomach Acid (think ulcers/NSAID use/Steroid use)
55
Chapman Reflex Points
Liver, Gallbladder (Cholecystitis)
Anterior:
Anterior: 6th intercostal space near sternum on R
56
Chapman Reflex Points
Stomach (Peristalsis)
Anterior:
Anterior: 6th intercostal space near sternum on L
Stomach Peristalsis (think of emptying time)
57
Chapman Reflex Points
Pancreas
Anterior:
Anterior: 7th intercostal space near sternum on R
58
Chapman Reflex Points
Spleen
Anterior:
Anterior: 7th intercostal space near sternum on L
59
Chapman Reflex Points
Adrenal Glands
Anterior:
Posterior:
Anterior: 1” Lateral and 2” Superior to Umbilicus Ipsilaterally
Posterior: Intertransverse Spaces of T11 and T12 Ipsilaterally Midway Between Spinous and Transverse Processes
60
Chapman Reflex Points
Kidneys
Anterior:
Posterior:
Anterior: 1” Lateral and 1” Superior to Umbilicus Ipsilaterally
Posterior: Intertransverse Spaces Midway Between Spines and Transverse Tips of T12-L1
61
Chapman Reflex Points
Urinary Bladder
Anterior:
Posterior:
Anterior: Umbilical Area (Periumbilical)
Posterior: Intertransverse Spaces Midway Between Spines and Transverse Tips of L1-L2
62
Chapman Reflex Points
Appendix
Anterior:
Posterior:
Anterior: Tip of the right 12th rib
Posterior: At the transverse process of T11
63
Cardiac Autonomics
Parasympathetics:
When considering arrhythmia:
Heart: CN X (Vagus nerve): OA, C1, C2 somatic dysfunction can affect CN X
Right vagus-via SA node and hyperactivity predisposes to sinus bradyarrhythmias.
Left vagus- via AV node where hyperactivity predisposes to AV blocks.
Vagus nerves have fibers course to them from the C-1 & C-2 nerve roots.
Heart may be reflexively slowed by other organ visceral afferents.
Pulmonary branches have strongest influence
64
Parasympathetic Innervation to the Heart
Cranial Nerve X (Vagus)
Jugular foramen, Occipitomastoid (OM) suture, OA, AA, C2
Right and Left sided distribution
Right side= SA node
Left side= AV node
(PS: minimal and isolated peripheral arteriolar innervation)
Minimal PS innervation: vasodilation of arterioles in periphery. Face blush, submax glands, parotid glands, tongue, penis
65
Parasympathetic Effects: Cardiac
Decreases contractility
Decreases conduction velocity
Increases arrhythmia (brady-arrhythmias)
66
Vagus nerve originates in the brainstem and exits through the jugular foramen. The jugular foramen is formed from the occipitomastoid suture, which is made up from the temporal bone and the occiput. So dysfunction affecting the vagus nerve could come from occipitomastoid suture compression.
Think what organs that might affect: If it comes from the right side of left side.
For example how may it affect heart rhythms
67
What happens to Vagus nerve in heart transplant patient?
Which techniques would not be effective due to this following the surgery? Suboccipital Release because Vagus nerve is cut****
68
Important Highlights
First rib elevation causes T1 to follow Type II mechanics to the opposite side
Example, if left rib is elevated, T1 would be RRSR
Feather’s Edge refers to feeling at Restrictive Barrier
After a History, you must do a Physical (for example observation, palpation, etc.).
Once these are done, along with any other diagnostic workup) then you can make an assessment and treatment plan.
69
Important Highlights
Congestive Heart Failure (decompensated), Acute Myocardial Infarction
Do not use lymphatic pump techniques on patients
Congestive Heart Failure, COPD
Do not treat in supine position
The sicker the patient is, the weaker the patient is, the more frail the patient is:
Use gentle techniques, for example rib raising, soft tissue inhibition, myofascial release, counterstrain, etc.
Do not use techniques like muscle energy which can wear out the patient. Do not use HVLA
70
Lymphatics
Heart and lungs drain predominantly to the right lymphatic duct
71
Treating Lymphatics
Examples:
* **(Thoracic inlet/outlet has to be cleared/opened/treated BEFORE ANY other lymphatic treatment)
* ** Another way of saying this is that you have to open myofascial pathways at the transition zones
Examples include:
Anterior cervical fascia release
Thoracic inlet myofascial release
Pectoral Traction
72
MI Somatic Diagnosis
Viscerosomatic reflexes T1-T6
Chapman reflex Myocardium:
- Anterior: 2nd intercostal space near sternum
- Posterior: between T2 and T3
Palpable changes left upper thoracic spine and ribs
Specific
- Anterior infarct: T2-3 L
- Inferior wall: T3-5L, C2
Right pectoralis major trigger point 5th intercostal space (ICS) associated with supraventricular tachyarrhythmia due to sympathetic nervous system
73
Hypertension
Hypertension: a statistically significant correlation has been demonstrated between hypertension and C6,T2,T6 somatic dysfunction pattern.
A cause-effect relationship has not been established
74
Hypertension: Common Functional Elements
Vascular and cardiac hypersensitivity to sympathetic stimuli
Prolonged sympathetic stimuli to the kidneys (T10-T11): THIS IS WHERE ACE INHIBITORS WOULD WORK
-Causes functional salt and water retention and increasing arterial pressure
Venoconstriction causing increased cardiac output with normal peripheral resistance
-Eventual increase in peripheral resistance to reduce cardiac output
Prolonged HTN causes baroreceptors in the carotid sinus to reset and maintain the increased arterial pressure
75
Atrial fibrillation
| HR ~150 to 110 (varies)
Thoracic vertebrae should be rotated to the right
76
Sinus tachycardia rate 140
Thoracic vertebrae should be rotated to the right
77
Acute anterior wall MI with ST elevations and Q waves in V1–V4 and aVL
Reciprocal inferior ST depressions
78
3rd degree AV block
Cervical vertebrae should be rotated to the left
79
Sinus bradycardia
Cervical vertebra should be rotated to the right
80
1st degree AV block
Cervical vertebra should be rotated to the left
81
Rib Raising Timing
Rib raising done for a short period of time (less than 2 minutes) will usually stimulate the sympathetic effects. For example, bronchodilation
Rib raising done for a longer period of time (greater than 2 minutes) will usually lessen the sympathetic effects.
82
Sympathetics: T1-T6 (T2-T7): Lung, Trachea, Bronchi, Visceral Pleura
```
Bronchodilation
Vasoconstriction
Increased Goblet cell production
Decreased number of ciliated cells
Increased thick, sticky secretions
Dries the mucous membranes
Decreased lymphatic/circulatory drainage
```
83
Sympathetics
| Increased sympathetic outflow:
Bronchodilation
Vasoconstriction
- -> diminishes nutrient supply to the tissues (incl. medications)
- -> reduces lymphatic and venous drainage
increased number of goblet cells
- leads to thick and sticky respiratory epithelium (hyperplasia) = decreased mobility of the mucous
- inhibits secretion -- leading to dryness and cracking of the mucosa allowing for secondary bacterial infections
84
Parasympathetics
Vagus Nerve (CNX)
CN IX,X – Carotid Body
BP, CO2, O2 Regulation
Bronchial glands inhibited
Increased Ciliated/Goblet Ratio: Thinning of Mucous
Bronchial muscles constriction
Evaluate OA, AA/C1, C2 (close proximity of Vagus)
Vagus (CN X) for the respiratory airways:
-Right and left
Parasympathetic dominance is important to keep the mucous secretions clear and saliva-like (but sticky).
- Makes secretions thinner
- Ease ciliary clearance
85
Parasympathetic Response
Contraction of bronchiolar smooth muscle (bronchoconstriction)
Thins secretions
Vasodilation (pulmonary)
Hering-Breuer reflex
-Unable to differentiate alveoli filled with air or fluid
-Respiratory excursion is limited
Respiratory centers sense low O2 levels and increase diaphragmatic rate
Overall response: Shallow Breathing at a Rapid Rate
Responsible for production of profuse, clear, thin secretions from mucosa of the nasopharynx and sinuses
86
Increased Parasympathetic Activity
Bronchoconstriction
Increased clear, thin, watery secretions of glands
Improved/increased drainage
87
Lymphatics
| Response to Disease
Flattening of the diaphragm causes stagnation of lymph
- Increased tissue congestion
- Decreased cardiac output
- Associated with increased infection, mortality, prolonged healing time, fibrosis and scarring
88
Treating Lymphatics
Examples:
Thoracic inlet/outlet has to be cleared/opened/treated BEFORE ANY other lymphatic treatment)
***Examples include:
Anterior cervical fascia release
Thoracic inlet myofascial release
Pectoral Traction
89
Thoracoabdominal Diaphragm
Must evaluate neurological influence versus biomechanical influence
- Neurologically: Phrenic Nerve/C3, C4, C5
- Biomechanically: Where the thoracoabdominal diaphragm attaches: lower ribs, thoraco-lumbar junction, T10-L3 are examples.
90
Rib Raising
Rib raising done for a short period of time (less than 2 minutes) will usually stimulate the sympathetic effects. For example, bronchodilation
Rib raising done for a longer period of time (greater than 2 minutes) will usually lessen the sympathetic effects.
91
Thoracic Diaphragm: Physiology
Thoracic Diaphragm motion increases the volume of the thorax in Three Planes of Motion
*Inferior/Superior (limited by mediastinum)
*Transverse (Ribs 6-12, bucket-handle motion)
*Anterior/Posterior (Ribs 1-5, pump-handle)
Dome of the Diaphragm
*zone of apposition
Posture: Diaphragm’s greatest excursion is in the supine position
92
Diaphragm - Lymphatic Pump
Lymphatic Drainage:
Affected by contraction of the diaphragm & thoracic cage motion
Assists in fighting infection
Prevents tissue congestion
Has a piston-like motion
*Flattens and moves inferior with inhalation when skeletal muscle contracts
*Domes upward and ascends with exhalation as skeletal relaxes
93
Diaphragm
| Consequences of Impaired Diaphragmatic Mobility:
```
Shortness of Breath
Less effective gas exchange in the lungs
Retention of Pulmonary Secretions
Constipation and Other Bowel Dysfunctions
Backache
Pelvic Congestion, Dysmenorrhea
Hemorrhoids
Leg Edema, Varicosities, Night Cramps
Headache, Irritability, Malaise, Dizziness, Confusion
```
94
Bronchial Asthma: Signs / Symptoms
Dyspnea / Wheezing
Use of Accessory muscles
Positioning, patient will brace him/herself (Tripod position)
95
Bronchial Asthma: Treatment
Acute attack
- Address immediate needs (monitor vitals)
- Oxygen
- Medications (β2 agonists, Anticholinergic, Steroids)
- Nebulizers
Once stable
-OMT
(NEVER use Thoracic pump WITH respiratory Assist during acute attack)
Between attacks
-Treat all components of respiratory system
96
COPD: Musculoskeletal Changes
```
Barrel shaped chest
↑ AP diameter
↑ Transverse diameter
Hypertophy of accessory muscles
May lead to neurovascular impingement (thoracic outlet syndrome)
What else may this lead to? For example, decreased lymphatic drainage
Decreased rib motion
Thoracic kyphosis
```
Restricted motion of the diaphragm
Flattened diaphragm (Diminished Zone of Apposition)
Decreased lymphatic drainage will occur because rib cage and diaphragm are not moving well
97
Asthma/COPD
May be on steroids for extended periods of time
- What may be the side-effects? Osteoporosis, diabetes mellitus, adrenal insufficiency
- Where would you find viscerosomatic changes, Chapman points related to diabetes and adrenal insufficiency?
- What would you see on imaging, lab work for above side-effects?
If someone has taken steroids for an asthma and hasn’t tapered off after heavy dosing for an extended time, what are you concerned about? For example adrenal insufficiency. The patient may present with fatigue, because adrenals aren’t working like they should. They stopped working because receiving exogenous steroids.
What are you concerned about with OMT in Asthma/COPD?
What treatment position is best avoided and why? Supine, they feel they can’t breathe.
What techniques should be avoided in an asthmatic attack or exacerbation of COPD? Thoracic pump with respiratory assist (recoil)
98
Important Highlights
COPD
Do not treat in supine position (will feel like they are suffocating/can’t breathe)
The sicker the patient is, the weaker the patient is, the more frail the patient is:
Use gentle techniques, for example rib raising, myofascial release, counterstrain, etc.
Do not use techniques like muscle energy which can wear out the patient. Do not use HVLA, do not use lymphatic pump techniques.
99
Rib Motions
Pump-Handle motion
Primarily ribs 1-5
Palpation of Pump Handle Ribs: best at Mid-clavicular Line
Bucket-Handle motion
Primarily ribs 6-10
Palpation of Bucket Handle Ribs: best at Mid-axillary Line
Caliper motion
Primarily ribs 11,12
100
Pump Handle Motion
Predominantly ribs 1-5
Ribs move anterior and superior with inhalation
Motion predominantly in sagittal plane
Best palpated at mid-clavicular line
Axis of motion is costovertebral-costotransverse line
101
Bucket Handle Motion
Predominantly ribs 6-10
Ribs move laterally and increase transverse diameter with inhalation
Motion predominantly in coronal plane
Best palpated at mid-axillary line
Axis of motion is a costovertebral-costosternal line
102
Inhalation Rib Somatic Dysfunction
Somatic dysfunction usually characterized by a rib being held in a position of inhalation
Motion toward inhalation is more free
Motion toward exhalation is restricted
Patient may complain of pain with EXHALATION
```
Synonyms:
Exhalation rib restriction
Inhalation strain
Elevated rib
Inhaled rib
```
103
Exhalation Rib Somatic Dysfunction
Somatic dysfunction usually characterized by a rib being held in a position of exhalation
Motion toward exhalation is more free
Motion toward inhalation is restricted
Patient may complain of pain with INHALATION
```
Synonyms:
Inhalation rib restriction
Exhalation strain
Depressed rib
Exhaled rib
```
104
Rib Information
B.I.T.E
Bottom Rib is key rib in Inhalation dysfunction
Top Rib is key rib in Exhalation dysfunction
Exhaled ribs are prominent posteriorly
Inhaled ribs are prominent anteriorly
Anterior Rib Counterstrain Points are associated with Exhalation Rib Somatic Dysfunction
Posterior Rib Counterstrain Points are associated with Inhalation Rib Somatic Dysfunction
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If pain increases when patient inhales:
pain increases when patient exhales:
If left ribs 2-5 lag on exhalation as compared to the right side:
indicates exhalation rib somatic dysfunction
indicates inhalation rib somatic dysfunction
then left ribs 2-5 are dysfunctional and represent inhalation somatic dysfunction. The key rib would be rib 5 and the muscle that may have caused this is pectoralis minor. Rib 5 is holding up rib 2, 3,4 and won’t let them exhale. Rib 5 is the BOTTOM rib causing the dysfunction.
Other findings that may be present:
There may be posterior rib counterstrain points associated with inhalation rib somatic dysfunction
Ribs would be prominent anteriorly with inhalation rib somatic dysfunction
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If left ribs 2-5 lags on inhalation as compared to the right side,
then left ribs 2-5 are dysfunctional and represent exhalation somatic dysfunction. The key rib would be rib 2. Rib 2 is holding down rib 3, 4, 5 and won’t let them inhale. Rib 2 is the TOP rib causing the exhalation rib somatic dysfunction.
Other findings that may be present:
There may be anterior rib counterstrain points associated with exhalation rib somatic dysfunction
Ribs would be prominent posteriorly with exhalation rib somatic dysfunction
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Samples of how to diagnose ribs:
If right ribs have an increased 6th intercostal space (ICS), then at this point either rib 6 is inhaled or rib 7 is exhaled.
If right ribs have a decreased 6th intercostal space (ICS), then at this point either rib 6 is exhaled or rib 7 is inhaled.
Example: If right ribs have an increased 6th intercostal space (ICS), and they lag on inhalation, then you know it is an exhalation somatic dysfunction and therefore rib 7 is exhaled.
Example: if right ribs have an increased 6th intercostal space (ICS), and the patient has pain when they exhale, then you know it is an inhalation somatic dysfunction and rib 6 is inhaled.
Example: If right ribs have an increased 6th intercostal space (ICS), and there are anterior rib counterstrain points found on exam, then you know this represents an exhalation somatic dysfunction and rib 7 is exhaled.
Example: If right ribs have an increased 6th intercostal space (ICS), and the ribs are prominent posteriorly, then you know it is an exhalation somatic dysfunction and rib 7 is exhaled.
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Samples of how to diagnose ribs
Prominent ribs posteriorly would indicate exhalation somatic dysfunction
Prominent ribs anteriorly would indicate inhalation somatic dysfunction
Anterior rib counterstrain points would indicate exhalation somatic dysfunction
Posterior rib counterstrain points would indicate inhalation somatic dysfunction
Another sample question: If ribs 2-8 lag on exhalation, which muscle might have caused this? So you know it is an inhalation somatic dysfunction and that 8 is the key rib in inhalation somatic dysfunction (B.I.T.E). Muscles used to treat exhaled ribs may become hypertonic and lead to an inhalation somatic dysfunction. Since serratus anterior is associated with rib 8, that is the muscle that has now caused the inhalation somatic dysfunction!
Note: Piece all the findings giving to you from questions to formulate what the rib diagnosis is, what muscles may have caused it, how do you set them up for treatment if inhalation versus exhalation muscle energy, etc.
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Anterior Rib Tender Points
Tender Point Locations:
AR1
AR2
AR3-10
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AR1
Below clavicle on 1st chondrosternal articulation associated with pectoralis major and internal intercostal muscles
AR2
Superior aspect of 2nd rib in midclavicular line
AR3-10
On the dysfunctional rib at the anterior axillary line associated with the serratus anterior (AR3-8) and internal intercostal muscles (AR9-10)
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Treatment of AR1-2 Tender Points - STRT
The patient lies supine and the physician stands or sits at the head of the table.
The physician passively flexes patient's head and neck to engage the dysfunctional rib level.
The patient's head and neck are side-bent and rotated toward the tender point
The physician fine-tunes through small arcs of motion (flexion, extension, side bending, or rotation).
The physician holds this position for 90 seconds
Reassess!
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Treatment of AR3-10 Tender Points - STRT
The patient is seated with the hips and knees flexed on the table on the side of the tender point. The patient may let the leg on the side of the tender point hang off the front of the table, the other leg crossed under it.
The physician stands behind the patient with the foot opposite the tender point on the table and the thigh under the patient's axilla (induces side bending toward tender point).
The patient's thorax is slightly flexed to the dysfunctional level.
The patient's arm opposite the tender point is draped over physician's leg. The patient’s arm on the side of the tender point is extended and allowed to hang off the edge of the table behind the patient, inducing rotation toward and translation away (sidebending toward) the tender point.
The physician fine-tunes through small arcs of motion (flexion, extension, side bending, or rotation).
The physician holds this position for 90 seconds.
Reassess!
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Posterior Rib Tender Points
Indications:
Somatic dysfunction of ribs 1-6 (commonly inhaled)
Rib 1
Rib 2-6
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Rib 1:
Pain in cervicothoracic junction
Ribs 2-6:
Pain in upper to mid-thoracic and/or periscapular region
May be caused by trauma, overhead sleeping position or sudden movement of neck or thorax
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Posterior Rib Tender Points
Locations:
PR1:
PR2-6:
PR7-10
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PR1:
On posterior superior aspect of 1st rib at cervicothoracic angle immediately anterior to trapezius
PR2-6:
On superior aspect of angle of dysfunctional rib associated with the levatores costarum and/or serratus posterior superior muscles
PR7-10:
On superior aspect of angle of dysfunctional rib associated with the levatores costarum
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Treatment of PR1 Tender Point - STRT
The patient is seated. The physician stands behind the patient.
The physician's foot is placed on the table on the same side as the tender point.
The physician monitors the first rib tender point with the index finger pad, which is on the tender point
With the other hand, the physician side-bends the head and neck toward the tender point, then gently flexes or extends the head and neck, carefully monitoring the movement so it is vectored to engage the first rib.
The physician fine-tunes through small arcs of motion (flexion, extension, rotation, and side bending).
The physician holds this position for 90 seconds.
Reassess!
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Treatment of PR2-10 Tender Points - SARA
The patient is seated with legs on the side of table (for comfort, the patient may hang the leg opposite the tender point off the table).
The physician stands behind patient with the foot ipsilateral to the tender point on the table with the thigh under the patient's axilla.
The physician gently flexes patient's head, neck, and thorax to engage the level of the dysfunctional rib.
The physician elevates the patient's shoulder with the axilla resting on the thigh, which side-bends the trunk away from the tender point.
The patient is asked to slowly extend the shoulder and arm opposite the tender point and allow the arm to hang down. This induces side bending away (translation towards) and rotation away from the tender point.
The physician fine-tunes through small arcs of motion (flexion, extension, rotation, and side bending).
The physician holds this position for 90 seconds.
Reassess!
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Supine Thoracic HVLA: T7 NSLRR
Patient is supine and physician standing on the left side of the patient (stand on the opposite side of the posterior transverse process)
Patient crosses arms opposite over adjacent
Physician places left thenar eminence (caudad hand) under the posterior transverse process of the dysfunctional segment
Side-bend the patient to the right (away from you) engaging the restrictive barrier
The patient forms a “smiley” face from your viewpoint
Have the patient take a deep breath in and exhale out
At the end of exhalation, apply a HVLA thrust straight down toward your fulcrum (thenar eminence)
Recheck your findings
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Supine Thoracic HVLA: T7 FSRRR
Patient is supine and physician standing on the left side of the patient (stand on the opposite side of the posterior transverse process)
Patient crosses arms opposite over adjacent
Physician places left thenar eminence (caudad hand) under the posterior transverse process of the dysfunctional segment
Sidebend the patient to the left (toward you) engaging the restrictive barrier
The patient forms a “frowny” face from your viewpoint
Have the patient take a deep breath in and exhale out
At the end of exhalation, apply a HVLA thrust straight down toward your fulcrum (thenar eminence)
Recheck your findings
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Supine Thoracic HVLA: T7 ESRRR
Patient is supine and physician standing on the left side of the patient (stand on the opposite side of the posterior transverse process)
Patient crosses arms opposite over adjacent
Physician places left thenar eminence (caudad hand) on the right transverse process below the dysfunctional segment
With your cephalad hand, flex the patient’s torso to the T7-T8 joint space
Side-bend the patient to the left (towards you) engaging the restrictive barrier (the patient forms a “frowny” face from your viewpoint)
Have the patient take a deep breath in and exhale out
At the end of exhalation, apply a HVLA thrust directed 45 degrees cephalad toward your fulcrum (thenar eminence)
Recheck your findings
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Muscle Energy
| Inhalation Dysfunction Ribs 1 - 10
Patient is supine, physician at head of table
Pump-handle ribs
Flex the patient’s head and neck
Bucket-handle ribs
Flex and Side-bend the patient towards dysfunctional rib
Physician places a hand, thumb, or fingers on the anterior, superior surface of the rib
Patient inhales deeply and holds for 3-5 seconds
Physician resists inhalation motion of rib
effecting an isometric contraction
Patient exhales, physician follows the rib into exhalation
Physician takes up the slack, and adjusts flexion/side-bending after a 2 second pause
The process is repeated 3-5 times
Reassess
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Muscle Energy
| Exhalation Dysfunction Ribs 1 – 10
Patient supine, physician at head of table
The patient is instructed to place their arm in the correct position as directed by the physician in order to use the correct muscle during the treatment.
Physician contacts the key rib posteriorly at the rib angle.
Patient inhales while the physician applies an inferior force to the rib angle
At full inhalation, the patient is instructed to hold his/her breath while performing an isometric contractions, pushing with their arm into the physicians resistance, for 3-5 seconds.
The process is repeated 3-5 times and then rib motion is re-assessed.
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Muscles used in Muscle Energy to Treat Rib Exhalation Somatic Dysfunction
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Rib 1: Anterior and mid scalene
Rib 2: Posterior Scalene
Ribs 3 – 5: Pectoralis Minor
Ribs 6 – 8: Serratus anterior
Ribs 9 – 11: Latissimus Dorsi
Rib 12: Quadratus Lumborum
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NOTE: If these muscles become hypertonic, they can cause an inhalation somatic dysfunction!!!!
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Muscle Energy
| Exhalation Dysfunction Rib 1
Anterior and middle scalene muscles attach to rib 1
Contraction of these muscles help mobilize the exhaled rib
Patient supine, physician at head of table
The patient’s hand on their forehead palm up
Physician grasps rib 1 posteriorly at the rib angle
Patient inhales, physician applies an inferior traction to the rib angle
At full inhalation, the patient is instructed to hold his/her breath while lifting their head anteriorly, physician resists this motion for 3-5 seconds.
The process is repeated 3-5 times and then rib motion is reassessed.
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Muscle Energy
| Exhalation Dysfunction Rib 2
Posterior scalene muscle attaches to rib 2
Contraction of this muscle help mobilize the exhaled rib
Patient supine, physician at head of table
The patient’s hand on their forehead palm up and rotates away
Physician grasps rib 2 posteriorly at the rib angle
Patient inhales, physician applies an inferior traction to the rib angle
At full inhalation, the patient is instructed to hold his/her breath while lifting their head anteriorly, physician resists this motion for 3-5 seconds.
The process is repeated 3-5 times and then rib motion is reassessed
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Muscle Energy
| Exhalation Dysfunction Rib 3-5
Pectoralis Minor muscle attaches to ribs 3, 4, 5
Contraction of these muscles help mobilize the exhaled rib
Patient supine, physician at head of table
The patient’s hand on their forehead palm up
Physician grasps rib 3, 4, 5 posteriorly at the rib angle
Patient inhales, physician applies an inferior traction to the rib angle
At full inhalation, the patient is instructed to hold his/her breath and pushes their elbow to their contralateral ASIS, physician resists this motion for 3-5 seconds
The process is repeated 3-5 times and then rib motion is reassessed.
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Muscle Energy
| Exhalation Dysfunction Rib 6-8
Serratus Anterior muscle attaches to ribs 6, 7, 8
It attaches to other ribs as well but the angle of attachment to these ribs is what assists in the treatment
Contraction of these muscles help mobilize the exhaled rib
Option 1
Patient supine, physician at head of table
The patient’s hand behind their head, elbow pointing straight up
Physician grasps rib 6, 7, 8 posteriorly at the rib angle
Patient inhales, physician applies an inferior traction to the rib angle
At full inhalation, the patient is instructed to hold his/her breath and pushes their elbow toward the ceiling, physician resists this motion for 3-5 seconds
The process is repeated 3-5 times and then rib motion is reassessed.
Option 2
Patient supine, physician at head of table
The patient’s hand on their forehead palm up
Physician grasps rib 6, 7, 8 posteriorly at the rib angle
Patient inhales, physician applies an inferior traction to the rib angle
At full inhalation, the patient is instructed to hold his/her breath and pushes their elbow to their ipsilateral ASIS, physician resists this motion for 3-5 seconds
The process is repeated 3-5 times and then rib motion is reassessed.
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Muscle Energy
| Exhalation Dysfunction Rib 9-10
Latissimus dorsi muscle attaches to ribs 9, 10, 11
Contraction of these muscles help mobilize the exhaled rib
Option 1
Patient supine, physician at head of table
The patient’s hand on their forehead palm up
Physician grasps rib 9, 10 posteriorly at the rib angle
Patient inhales, physician applies an inferior traction to the rib angle
At full inhalation, the patient is instructed to hold his/her breath and ADduct their arm, physician resists this motion for 3-5 seconds
The process is repeated 3-5 times and then rib motion is reassessed.
Option 2
Patient supine, physician at head of table
The patient’s arm is ABducted
Physician grasps rib 9, 10 posteriorly at the rib angle
Patient inhales, physician applies an inferior traction to the rib angle
At full inhalation, the patient is instructed to hold his/her breath and ADduct their arm, physician resists this motion for 3-5 seconds
The process is repeated 3-5 times and then rib motion is reassessed.
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HVLA Seated Inhaled Rib 1
Physician stands behind and places his contralateral foot onto the table
Patient drapes contralateral arm over physician’s leg and leans against the leg
Physician places ipsilateral 2nd MCP joint (thrusting hand) over the rib head
Physician places the contralateral hand to sidebend the cervical spine towards the dysfunctional rib and rotates head away from dysfunctional rib
Slack is taken up (patient exhales)
Thrust is directed caudal and medial as the sidebending is exaggerated
NOTE: Apply ONLY about 5% of your force to the patient’s head or neck!!!
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Rib HVLA 2-10 (Inhalation or Exhalation)
Similar to Thoracic Supine HVLA (Kirkesville Crunch)
Place thenar eminence (fulcrum) on posterior aspect of rib angle instead of transverse process
For exhalation rib HVLA, your thenar eminence on the rib angle will pull downward (inferior/caudad) on rib angle
For inhalation rib HVLA , your thenar eminence on the rib angle will push upward (superior/cephalad) on rib angle
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Please look over indications/contraindications for indirect and direct techniques:
For example if a patient is unable to follow commands (ie: due to language barriers, dementia(confusion), delirium (confusion) they can not participate in M.E. because they can not follow commands to push against resistance, etc.
