Exam 3 Flashcards
1
Q
For ANY disease state, the patient must be ____ before performing OMT
A
STABLE
2
Q
The sicker/weaker/more injured a patient is, use ___________ (examples include rib raising, myofascial release(MFR) soft tissue, etc.)
A
gentler techniques
3
Q
Somatic dysfunction can occur anywhere in the body at
A
Sympathetics levels
Paraysmpathetic levels
Soma (not autonomic related)
4
Q
Viscerosomatic reflexes occur at
A
Sympathetics levels
Parasympathetics levels
5
Q
Facilitated segments ONLY occur at
A
Sympathetics
6
Q
Know your sympathetic levels, parasympathetic levels. If sympathetic is not in your answer choices, see if a parasympathetic level to that organ is present (lot of people tend to forget about the parasympathetics). For example, upper (proximal) ureters sympathetically are T10-T11, and the parasympathetic innervation is vagus ________ can affect the upper (proximal) ureters.
A
(so OA, AA (C1), C2
7
Q
Viscerosomatic reflexes can be both sympathetic and parasympathetic, but if a questions asks where you would see paravertebral hypertonicity, keep in mind where the paraspinal muscles are. For example the sacrum does not have paraspinal muscles at S2-S4, but ____ would.
A
T12-L2
8
Q
Thoracic Pump with respiratory assist is CONTRAINDICATED in a patient with ___________
A
Asthmatic Flare Up or COPD exacerbation
9
Q
Thoracoabdominal diaphragm: Must evaluate neurological influence versus biomechanical influence
A
Neurologically: Phrenic Nerve (C3, C4, C5)
Biomechanically: Where the thoracoabdominal diaphragm attaches: lower ribs, thoraco-lumbar junction, T10-L3 are examples.
10
Q
If a patient has been sick recently and has had swollen glands/nodes in the neck and you suspect Mono, you worry about the person developing _______. If they are injured in a trauma, such as a sport, they may get a referral pain to the shoulder and if the spleen ruptures they can go into shock: low blood pressure/increased heart rate. They may lose consciousness. THIS IS A SURGICAL EMERGENCY!
A
splenomegaly
11
Q
Young males should not get recurrent urinary tract infections: must do _____
A
imaging studies of the uro-genital anatomy
12
Q
Gallbreath technique
A
Great for treating otitis media, fluid in the ear, Eustachian tube somatic dysfunction
13
Q
Internal rotation of the temporal bone partially or completely closes the Eustachian tube and may result in the _________
A
perception of a high-pitched ringing in the ear.
14
Q
External rotation of the temporal bone may open the Eustachian tube and result in the ____________
A
perception of a low-pitched roar
15
Q
A parallelogram-shaped head in an infant is associated with a __________
A
lateral strain cranial pattern
16
Q
B.I.T.E
A
Bottom Rib is key rib in Inhalation dysfunction
Top Rib is key rib in Exhalation dysfunction
17
Q
Remember, sometimes muscle hypertonicity, contraction, spasm can be caused by direct irritation of the what is overlying the muscle:
A
For example, if there is a renal lithiasis, it may cause the psoas to become hypertonic and you would have a positive Thomas test
For example, if there is appendicitis, it may cause the psoas to become hypertonic and you would have a positive Thomas test
For example, if there are inflamed lymph nodes, this may make the muscle they are touching to become hypertonic such as sternocleidomastoid causing torticollis
18
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.
A
For example, if it is found at T2 you would think more pulmonary issue and maybe albuterol might be answer choice
For example, if it is found at T8 you would think this is more GI and maybe omeprazole might be answer choice
For example if it is found at T5 that could be either pulmonary or GI and you would need more information to get correct answer
19
Q
Treating a facilitated segment would help avoid excessive neurologic impulse through the ______
A
viscerosomatic reflex arc
20
Q
Later stages of chronic facilitation is associated with _____
A
loss of inhibitory neurons
21
Q
RVU:
A
Relative Value Unit
22
Q
Lumbar spine will side-bend towards the ____ and rotate towards the ____ (Type I like mechanics)
A
long leg side
short leg side
23
Q
Most commonly used form of contraction in muscle energy is
A
isometric contraction
24
Q
Take a history prior to
A
physical exam
25
__________ the patient move is the first part of the physical examination
Observation/observing
26
________ used in muscle energy tenses the Golgi Tendon organs causing a reflex inhibition of the muscle allowing an increase in muscle length
Isometric contraction
27
A heel lift for a leg length difference may help prevent ______ in a patient
osteoarthritis
28
Feather’s Edge refers to the
RESTRICTIVE BARRIER
29
Acute:
```
Recent history (injury)
Sharp or severe localized pain
Warm, moist, sweaty skin
Boggy, edematous tissue
Erythematous
Local increase in muscle tone, contraction, spasm, increased muscle spindle firing
Normal or sluggish ROM
May be minimal or no somatovisceral effects
```
30
Chronic
```
Long-standing
Dull, achy diffuse pain
Cool, smooth, dry skin
Possible atrophy
Fibrotic, ropy feeling tissue
Pale/skin pallor
Decreased muscle tone, contracted muscles, sometimes flaccid
Restricted ROM
Somatovisceral effects more often present
```
31
Orientation of superior facets:
Cervical
Thoracic
Lumbar
BUM
BUL
BM
32
Orientation of inferior facets:
Cervical
Thoracic
Lumbar
AIL
AIM
AL
33
In axial spine, the reference point is the _____ aspect of the vertebra
superior/anterior
34
Rotation: Movement in a _______ plane about a _____ axis
transverse
| vertical
35
Sidebending: Movement in a _____ plane about a _____ axis
coronal
| anterior-posterior
36
Flexion: Anterior movement in a ____ plane about a ____ axis
sagittal
| transverse
37
Extension: Posterior movement in a _____ plane and a _____ axis
sagittal
| transverse
38
Fryette Law 1
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
Diagnosed as a Type I dysfunction
39
Fryette Law 2
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
Diagnosed as a Type II dysfunction
May be described as traumatic injury
40
_______ side-bends to one side and rotates to opposite , whether there is a sagittal component or not (Type I like)
OA joint
| OA Joint Accounts for 50% of Total C-Spine FLEXION/EXTENSION
41
______ primarily rotational
AA joint
| AA Joint Accounts for 50% of Total C-Spine ROTATION
42
_____ rotate and side-bend to same side , whether there is a sagittal component or not (Type II like)
C2-C7
43
Rule of 3's:
_______: spinous processes project posteriorly therefore the tip of the spinous process is in the same plane as the transverse process of that vertebra
T1-T3 and T12
44
Rule of 3's:
_______: spinous processes project slightly downward, therefore the tip of the spinous process lies in a plane halfway between that vertebra’s transverse processes and the transverse processes of the vertebra below it
T4-T6 and T11
45
Rule of 3's:
_______: spinous processes project moderately downward, therefore the tip of the spinous process is in a plane with the transverse process below it
T7-T9 and T10
46
```
Counterstrain
Facilitated Positional Release (FPR)
Balanced Ligamentous Tension Technique (BLT)
Functional Technique
*Myofascial Release
*Cranial
**Still Technique
```
Indirect techniques
* Can be direct
* *Indirect to direct
47
```
*Myofascial Release
Soft tissue
Articulatory
Muscle Energy
High velocity, low amplitude (HVLA)
Springing
*Cranial
**Still Technique
```
Direct techniques
* Can be indirect
* *Indirect to direct
48
_____ Muscle Energy
| Patient is Instructed to GENTLY Push AWAY From the Barrier
Post-isometric
49
_____ Muscle Energy
| Patient is Instructed to GENTLY Push TOWARD the Barrier
Reciprocal inhibition
50
```
Sympathetic Levels:
Kidneys
Adrenal Medulla
Upper Ureters
Lower ureters
Bladder
Gonads
Uterus/Cervix
Erectile tissue
Prostate
Arms
Legs
```
```
T10-T11
T10
T10-T11
T12-L1
T12-L2
T10-T11
T10-L2
T11-L2
T12-L2
T2-T8
T11-L2
```
51
Parasympathetic
| kidneys and proximal ureter
Vagus nerve (OA, AA, C2)
52
Parasympathetic
| Distal ureter, bladder, reproductive organs and external genitalia
S2-S4
53
Parasympathetic
| Ovaries and testes
Variations:
| Vagus and S2-S4
54
Peripheral Sympathetic Supply:
UE Vasculature ____
LE Vasculature ____
T2-T8
T11-L2
***No parasympathetic supply to LE/UE
55
Sympathetic Innervation
| Lesser Splanchnic Nerve (T10-11) - synapses at _____
Superior Mesenteric Ganglion
| Kidney, upper ureter, gonads
56
Sympathetic Innervation
| Least Splanchnic Nerve (T12) and Lumbar Splanchnic Nerve (L1-2) - synapses at _____
Inferior Mesenteric Ganglia
| Prostate, lower ureter, bladder
57
(Thoracic inlet/outlet has to be cleared/opened/treated _____ ANY other lymphatic treatment)
BEFORE
58
Thoracic inlet/outlet components:
Supraclavicular space
| 1st rib
59
Treatment examples for lymphatics include:
Anterior cervical fascia release
Thoracic inlet myofascial release
Pectoral Traction
60
Chapman Reflex Point - Adrenal Gland
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
61
Chapman Reflex Point - Kidneys
Anterior:
Posterior:
Anterior: 1” Lateral and 1” Superior to Umbilicus Ipsilaterally
Posterior: Intertransverse Spaces Midway Between Spines and Transverse Tips of T12-L1
62
Chapman Reflex Point - Urinary Bladder
Anterior:
Posterior:
Anterior: Umbilical Area (Periumbilical)
Posterior: Intertransverse Spaces Midway Between Spines and Transverse Tips of L1-L2
63
Chapman Reflex Point - Urethra
Anterior:
Posterior:
Anterior: Along superior margin of the pubic ramus about 2 cm lateral to the symphysis
Posterior: L3 transverse processes
64
Sympathetics
Heart: T1-6 with synapses in upper thoracic and cervical chain ganglia.
When considering arrhythmia:
Right and left-sided distributions
Right- sinoatrial (SA) node and right deep cardiac plexus– predisposes to _________
Left-atrioventricular (AV) node and left deep cardiac plexus- predisposes to _________
Asymmetries in sympathetic tone may play a role in the generation of serious arrhythmias.
supraventricular tachyarrhythmias. Sinus tach, A-fib, A-flutter, PACs
ectopic PVCs and V fib and V tach
65
Parasympathetic - Heart
Right vagus-via SA node and hyperactivity predisposes to ______
Left vagus- via AV node where hyperactivity predisposes to ____
Vagus nerves have fibers course to them from the C-1 & C-2 nerve roots.
sinus bradyarrhythmias.
AV blocks.
66
```
Parasympathetic Innervation to the Heart
Cranial Nerve X (Vagus)
Jugular foramen, Occipitomastoid (OM) suture, OA, AA, C2
Right and Left sided distribution
Right side= ____
Left side= ____
```
SA node
AV node
(PS: minimal and isolated peripheral arteriolar innervation)
67
Sinus Bradyarrhythmia:
OA, AA (C1), C2 will rotate towards the right (Right side is SA node)
68
1st, 2nd, 3rd degree AV Blocks:
OA, AA (C1), C2 will rotate towards the left (Left side is AV node)
69
Sinus Tachyarrhythmia, Atrial Fibrillation, Atrial Flutter, Premature Atrial Contractions (PAC):
Upper thoracic spine (T1-T5) will rotate towards the right (Right side is SA node)
70
V-fib, V-Tach, Premature Ventricular Contractions (PVC):
Upper thoracic spine (T1-T5) will rotate towards the left (Left side is AV node)
71
Vagus nerve originates in the brainstem and exits through the _______ The jugular foramen is formed from the ________ suture, which is made up from the temporal bone and the occiput. So dysfunction affecting the vagus nerve could come from ______ suture compression.
jugular foramen.
occipitomastoid
occipitomastoid
72
AV flutter
Thoracic vertebrae should be rotated to the right
73
```
Dry mouth (Xerostomia)
Can be caused by Cranial Nerve VII - (lacrimal glands, sublingual and submandibular glands). Remember CN VII is associated with the ______ ganglion and exits through the _______
```
Can be caused by Cranial Nerve IX - (parotid gland). Remember CN IX is associated with the ____ ganglion and exits through the_____ foramen
Sphenopalatine (Pterygopalatine); stylomastoid foramen
Otic; jugular
74
Anterior Tender Point: AT1
Location:
Treatment Position:
Midline or just lateral to the jugular (suprasternal) notch
| Flexion
75
Anterior Tender Point: AT2
Location:
Treatment Position:
Midline or just lateral to the junction of manubrium and sternum (angle of Louis)
Flexion
76
Anterior Tender Point: AT3-AT5
Location:
Treatment Position:
Midline (or with some degree of sidedness) at level of corresponding rib
Flexion
77
Anterior Tender Point: AT6
Location:
Treatment Position:
Midline (or with some degree of sidedness) xiphoid–sternal junction
Flexion
78
Anterior Cervical CS Point: AC7
Location:
Treatment Position:
On the clavicular (lateral) attachment of the SCM
| F STRA
79
Sternocleidomastoid muscle (SCM) refers
pain lateral and behind the eye
80
Splenius Capitus muscle refers
pain to the vertex of the head
81
TMJ: Post Isometric ME
If patient can’t open mouth:
If patient can’t close mouth:
If patient’s jaw deviates to the left when the patient opens their mouth:
If patient’s jaw deviates to the right when the patient opens their mouth:
- physician opens patient’s mouth to restrictive barrier and patient tries to close mouth against resistance
- physician closes patient’s mouth to restrictive barrier and patient tries to open mouth against resistance
- physician pushes the patient’s jaw to the right and the patient tries to push their jaw to the left against resistance
- physician pushes the patient’s jaw to the left and the patient tries to push their jaw to the right against resistance
82
TMJ Masseter CS
Tender Point Location:
The physician gently glides the patient's slightly opened jaw/mandible laterally _____ side of the tender point
Masseter: Just inferior to the zygoma in the belly of the masseter muscle typically found on the side of mandibular deviation
toward
83
TMJ Medial Pterygoid CS
Tender Point Location:
The physician gently glides the patient's slightly opened jaw/mandible _____ side of the tender point
Jaw angle point or medial pterygoid: On the posterior surface of the ascending ramus of the mandible about 2 cm. above the angle of the mandible on the side opposite of mandibular deviation
laterally away
84
```
CN I
CN V
CN VII
CN VIII
CN X
CN XI
CN XII
```
Anosmia
Cribiform plate through ethmoid bone
Trigeminal Neuralgia/Tic Douloureux
May complain of sudden, severe facial, ear, and/or jaw pain
Exits stylomastoid foramen
Bell’s Palsy
Labyrinthitis, Tinnitus, Vertigo Temporal bone is associated with tinnitus, labyrnthitis, vertigo
Exits jugular foramen (formed by occipitomastoid suture)
Can cause Nausea/Vomiting
Exits jugular foramen (formed by occipitomastoid suture)
Can cause Torticollis
Hypoglossal canal
Can cause nursing/latching problems in infants
85
```
Complaints associated with CN impingement:
Difficulty nursing/latching
Colic
GERD
Vomiting
Torticollis
Asthma
Otitis Media
```
```
XII
X
X
X
XI
X
VIII
```
86
Pump handle motion
Primarily:
Palpation:
Primarily ribs 1-5
| Palpation of Pump Handle Ribs: best at Mid-clavicular Line
87
Bucket handle motion
Primarily:
Palpation:
Primarily ribs 6-10
| Palpation of Bucket Handle Ribs: best at Mid-axillary Line
88
Caliper motion:
| Primarily:
Primarily ribs 11,12
89
Somatic dysfunction usually characterized by a rib being held in a position of inhalation
Motion toward _____ is more free
Motion toward _____ is restricted
Pain with ____
Synonyms
Inhalation
Exhalation
Exhalation
Exhalation rib restriction
Inhalation strain
Elevated rib
Inhaled rib
90
Somatic dysfunction usually characterized by a rib being held in a position of exhalation
Motion toward _____ is more free
Motion toward _____ is restricted
Pain with ____
Synonyms
Exhalation
Inhalation
Inhalation
Inhalation rib restriction
Exhalation strain
Depressed rib
Exhaled rib
91
Exhaled ribs are prominent ____
Inhaled ribs are prominent ____
Anterior Rib Counterstrain Points are associated with ____
Posterior Rib Counterstrain Points are associated with
Posteriorly
Anteriorly
exhalation rib somatic dysfunction
inhalation rib somatic dysfunction
92
Samples how to diagnose ribs:
If pain increases when patient inhales:
If pain increases when patient exhales:
If left ribs 2-5 lag on exhalation as compared to the right side, 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 ______. Rib 5 is holding up rib 2, 3,4 and won’t let them exhale. Rib 5 is the ____ rib causing the dysfunction.
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 ___ rib causing the exhalation rib somatic dysfunction.
indicates exhalation rib somatic dysfunction
indicates inhalation rib somatic dysfunction
pectoralis minor.
BOTTOM
Other findings = There may be posterior rib counterstrain points associated with inhalation rib somatic dysfunction
Ribs would be prominent anteriorly with inhalation rib somatic dysfunction
TOP
Other findings = There may be anterior rib counterstrain points associated with exhalation rib somatic dysfunction
Ribs would be prominent posteriorly with exhalation rib somatic dysfunction
93
If right ribs have an increased 6th intercostal space (ICS), then at this point either
If right ribs have a decreased 6th intercostal space (ICS), then at this point either
rib 6 is inhaled or rib 7 is exhaled.
rib 6 is exhaled or rib 7 is inhaled.
94
Indications of Anterior Rib Tender Points:
Ribs 1-2: Pain in ____
Ribs 3-6: Pain in ____
Anterior chest wall
| Lateral chest wall
95
Anterior Rib Tender Point Locations:
AR1
AR2
AR3-10
Below clavicle on 1st chondrosternal articulation associated with pectoralis major and internal intercostal muscles
Superior aspect of 2nd rib in midclavicular line
On the dysfunctional rib at the anterior axillary line associated with the serratus anterior (AR3-8) and internal intercostal muscles (AR9-10)
96
Treatment of AR 1-2 Tender Points:
| Position =
F STRT
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
97
Treatment of AR 3-10 Tender Points:
| Position =
F STRT
The physician stands behind the patient with the foot opposite the tender point
Inducing rotation toward and translation away (side-bending toward) the tender point.
98
Indications of Posterior Rib Tender Points:
Rib 1: Pain in ___
Ribs 2-6: Pain in ____
Cervicothoracic junction
Upper to mid-thoracic and/or periscapular region
99
Posterior Rib Tender Point Locations:
PR1:
PR2-6:
PR7-10:
On the posterior superior angle of the first rib just lateral to the costotransverse articulation
On superior aspect of angle of dysfunctional rib associated with the levatores costarum and/or serratus posterior superior muscles
On superior aspect of angle of dysfunctional rib associated with the levatores costarum
100
Treatment of PR 1 Tender Point:
| Position =
ESART
The physician's foot is placed on the table on the opposite side as the tender point.
With the other hand, the physician gently extends and side-bends the head and neck away from the tender point, then, carefully monitoring the movement so it is vectored to engage the first rib.
The physician rotates the head toward the tender point.
101
Treatment of PR 2-10 Tender Points:
| Position =
FSARA
The physician stands behind patient with the foot ipsilateral to 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.
102
Inhalation Dysfunction ME
Pump handle ribs -
Bucket handle ribs -
Flex the patient’s head and neck
Flex the patient’s head and neck and side-bend the patient toward dysfunctional rib
Physician places a hand, thumb, or fingers on the anterior, superior surface of the rib
103
```
Exhalation Dysfunction ME
Ribs 1-10:
Rib 1:
Rib 2:
Ribs 3-5:
Ribs 6-8:
Ribs 9-10:
```
Physician contacts the key rib posteriorly at the rib angle.
R1: while lifting their head anteriorly
R2: rotates head away 30 degrees, while lifting their head anteriorly
R3-5: pushes their elbow to their contralateral ASIS
R6-8: pushes their elbow toward the ceiling OR pushes their elbow to their ipsilateral ASIS,
R9-10: ADduct their arm
104
```
Muscles used in ME to treat rib exhalation somatic dysfunction:
RIb 1
Rib 2
Rib 3-5
Rib 6-8
Ribs 9-11
Rib 12
```
```
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
```
NOTE: If these muscles become hypertonic, they can cause an inhalation somatic dysfunction!!!!
For example if you have a 4th inhalation rib somatic dysfunction, then pectoralis minor would be the hypertonic muscle
For example if a patient has a hypertonic pectoralis minor muscle on the right, what is the likely rib(s) that may be inhaled? 3-5
For example if rib 10 is an inhalation somatic dysfunction, latissimus dorsi would be the involved muscle
105
Rib HVLA 2-10 (Inhalation or Exhalation)
Place thenar eminence (fulcrum) on posterior aspect of ____ instead of transverse process
For exhalation rib HVLA, your thenar eminence on the rib angle will ______
For inhalation rib HVLA , your thenar eminence on the rib angle will ______
rib angle
```
pull downward (inferior/caudad) on rib angle
push upward (superior/cephalad) on rib angle
```
106
Short Leg Syndrome
Anatomical or functional
Signs and symptoms:
Heel life can be used to help prevent arthritis in person with short leg syndrome
Sacral base unleveling
Anterior innominate on side of short leg
Posterior innominate on side of long leg
L-spine will side-bend away from and rotate towards short leg
Lumbosacral (LS) angle will increase
Stress on iliolumbar ligaments then SI ligaments
107
Heel Lift Guidelines:
Final lift height should be _______
Start with 1/8” heel lift, then _______
Frail patients should start with 1/16” heel lift, then ______
½ – ¾ of the measured discrepancy. If acute discrepancy (i.e. hip fracture), lift full amount
increase by 1/8” every two weeks
increase by 1/16” every two weeks.
108
Heel Lift Guidelines:
1. The heel lift should be applied to the side of the short leg
2. The final lift height should be ½ - ¾ of the measured leg length discrepancy, unless there was a recent sudden cause of the discrepancy (hip fracture, prosthesis) then lift the full amount
3. The “fragile” patient (elderly, arthritic, osteoporotic, acute pain) should begin with a 1/16” (1.5 mm) heel lift and increase 1/16” every two weeks
4. The “flexible” should begin with 1/8” (3.2mm) heel lift and increase 1/8” every two weeks
5. A maximum of ¼” may be applied to the inside of the shoe (if >1/4” is needed, then this must be applied to the outside of the shoe
6. Maximum heel lift possible = ½”. If more is needed, an ipsilateral anterior sole lift extending from heel to toe should be used in order to keep the pelvis from rotating to the opposite side
For example, if a patient has an 8 mm leg length discrepancy chronically (Long Term), your goal is to lift to _____
4 mm
109
Standing Flexion Test:
Patient standing with feet flat on floor and shoulder width apart
Physician monitors the inferior aspect of patient’s PSIS
Patient forward bends maximally
Positive: side PSIS moves ______
Purpose: identifies side of sacroiliac somatic dysfunctions
“Gold Standard” Test for iliosacral SD
more cephalad at the end range of motion
110
ASIS Compression Test:
Apply a posterior-medial pressure on one ASIS while stabilizing the other.
Imagine aiming the pressure toward the SI joint.
Repeat the test on the other side.
The restricted side is _____
the positive side.
111
Seated Flexion Test:
Patient seated on stool with feet flat on floor and shoulder width apart
Physician monitors the inferior aspect of patient’s PSIS
Patient forward bends maximally
Positive: side PSIS moves ________
Purpose: identifies side of sacroiliac somatic dysfunctions
“Gold Standard” Test for _______
more cephalad at the end range of motion
| sacroiliac SD
112
innominate Rotation - Anterior
```
+ standing flexion (on side of the dysfunction)
ASIS Compression test + (on side of dysfunction)
____ ASIS (on side of the dysfunction)
____ PSIS (on side of the dysfunction)
____ ischial tuberosity (on side of the dysfunction)
____ sacral sulcus (on side of the dysfunction)
____ iliac crest height
____ medial malleolus (long leg) (on side of the dysfunction)
```
```
Inferior
Superior
Superior
Shallow
Equal
Inferior
```
113
```
Innominate Rotation - Posterior
+ standing flexion (on side of the dysfunction)
ASIS Compression test + (on side of dysfunction)
____ ASIS (on side of the dysfunction)
____ PSIS (on side of the dysfunction)
____ ischial tuberosity (on side of the dysfunction)
____ sacral sulcus (on side of the dysfunction)
____ iliac crest height
____ medial malleolus (long leg) (on side of the dysfunction)
```
```
Superior
Inferior
Inferior
Deep
Equal
Superior
```
114
```
Innominate Outflare (Abducted)
+ standing flexion (on side of the dysfunction)
ASIS Compression test + (on side of dysfunction)
ASIS ____ (on side of the dysfunction)
PSIS ____ (on side of the dysfunction)
Distance from ASIS to umbilicus _____ on dysfunctional side (is more lateral)
ASIS ____ from midline
_____ sacral sulcus (on side of the dysfunction)
```
```
Lateral
Medial
Increased
Further
Narrow
```
115
```
Innominate Inflare (Adducted)
+ standing flexion (on side of the dysfunction)
ASIS Compression test + (on side of dysfunction)
ASIS ____ (on side of the dysfunction)
PSIS ____ (on side of the dysfunction)
Distance from ASIS to umbilicus _____ on dysfunctional side (is more lateral)
ASIS ____ to midline
_____ sacral sulcus (on side of the dysfunction)
```
```
Medial
Lateral
Decreased
Closer
Wide
```
116
```
Superior Innominate Shear (Upslipped)
+ standing flexion (on side of the dysfunction)
ASIS Compression test + (on side of dysfunction)
_____ ASIS (on side of the dysfunction)
_____ PSIS (on side of the dysfunction)
_____ iliac crest height (on side of the dysfunction)
_____ pubic tubercle (on side of the dysfunction)
_____ ischial tuberosity (on side of the dysfunction)
_____ medial malleolus (on side of the dysfunction)
Sacrotuberous ligament ___ (on side of the dysfunction)
```
Superior
Lax
117
```
Inferior Innominate Shear (Downslipped)
+ standing flexion (on side of the dysfunction)
ASIS Compression test + (on side of dysfunction)
_____ ASIS (on side of the dysfunction)
_____ PSIS (on side of the dysfunction)
_____ iliac crest height (on side of the dysfunction)
_____ pubic tubercle (on side of the dysfunction)
_____ ischial tuberosity (on side of the dysfunction)
_____ medial malleolus (on side of the dysfunction)
Sacrotuberous ligament ___ (on side of the dysfunction)
```
Inferior
Tight
118
Superior Pubic Shear
+ standing flexion (on side of the dysfunction)
ASIS Compression test + (on side of dysfunction)
_____ pubic tubercle/ramus (on side of the dysfunction)
Ipsilateral inguinal ligament tense and tender
ASIS may be even or may be ______ (on side of the dysfunction)
PSIS may be even or may be ______ (on side of the dysfunction)
Findings may look similar to a _________
Superior
Superior
Inferior
Posteriorly rotated innominate
119
Inferior Pubic Shear
+ standing flexion (on side of the dysfunction)
ASIS Compression test + (on side of dysfunction)
_____ pubic tubercle/ramus (on side of the dysfunction)
Ipsilateral inguinal ligament tense and tender
ASIS may be even or may be ______ (on side of the dysfunction)
PSIS may be even or may be ______ (on side of the dysfunction)
Findings may look similar to a _________
Inferior
Inferior
Superior
Anteriorly rotated innominate
120
Anterior Innominate Rotation ME:
Patient supine
They are extending their hip
Patient using hamstrings
121
Posterior Innominate Rotation ME:
Patient can be supine or prone
They are flexing their hip
Patient using quads
122
Innominate In-Flare ME
Flex and abduct patients hip and knee and place in a figure 4 or frog leg position
123
Innominate Out-Flare ME
Flex the patient's hip and knee, adduct the knee across the midline, engaging the restrictive barrier
124
Superior Pubic Shear ME
Abduct the knee to gap the pubic symphysis
*Treated like a posterior innominate rotation with the addition of abduction
125
Inferior Pubic Shear ME
Abduct the thigh to gap the pubic symphysis
*Treated like an anterior innominate rotation with the addition of abduction
126
Innominate Up Slip ME
Internally rotate and slightly flex the hip and abduct to about 20 degrees.
Apply traction
127
```
Sacral Anatomical Axis
Transverse Axis:
Superior -
Middle -
Inferior -
```
the cranial primary respiratory mechanism creates motion around this axis
sacral base anterior and posterior (FB/BB) occur around this axis
sacrum flexes and extends around this axis (sagittal plane)
the innominates rotate around this axis relative to the sacrum
128
Sacral Somatic Dysfunction:
| Physiologic - dysfunction that occurs around a physiologic axis:
Transverse
| Oblique - neutral and non-neutral
129
Sacral Somatic Dysfunction:
| Non-physiologic - dysfunction that does not occur around an axis. Usually caused by trauma:
Unilateral sacral shear - unilateral sacral flexion/extension
130
The side of the posterior ILA is also ____
| The side of the anterior ILA is also ____
inferior
| Superior
131
Sacral Torsion Rules:
L5 Side-bends Towards _____
L5 Rotates Opposite _____
LOL
LOR
ROR
ROL
oblique axis
sacral rotation
L5 SLRR
L5 RRSR
L5 SRRL
L5 RLSL
132
Seated Flexion Tested +R:
LOL
ROL
RUF
RUE
133
Seated Flexion Tested +L:
ROR
LOR
LUF
LUE
134
Negative Seated Flexion Test
No SD
B/L sacral extension
B/L sacral flexion
135
Spring Test +:
(Non-neutral) - ROL, LOR
UE
B/L sacral extension
136
Spring Test -:
(Neutral): ROR, LOL
UF
B/L sacral flexion
137
Sphinx Test (Backward Bend Test) +
(Non-neutral): ROL, LOR
| UE
138
Sphinx Test (Backward Bend Test) -
(Neutral): ROR, LOL
UF
B/L sacral flexion
B/L sacral extension
139
```
B/L Sacral Flexion:
____ Seated Flexion Test
____ Lumbosacral Spring Test (Spring Test)
____ Sphinx Test (Backward Bending Test)
____ Sacral Sulci
____ Sacral Base
____ ILA bilaterally
____ Sacrotuberous ligaments b/l
```
```
Negative
Negative
Negative
Deep
Anterior
Posterior
Tight
```
140
```
B/L Sacral Extension:
____ Seated Flexion Test
____ Lumbosacral Spring Test (Spring Test)
____ Sphinx Test (Backward Bending Test)
____ Sacral Sulci
____ Sacral Base
____ ILA bilaterally
____ Sacrotuberous ligaments b/l
```
```
Negative
Positive
Negative
Shallow
Deep
Anterior
Loose
```
141
Forward Sacral Torsion (Neutral) - LOL ROR
_____ Seated Flexion Test (opposite side of axis)
_____ Lumbosacral Spring Test (Spring Test)
_____ Sphinx Test (Backward Bending Test)
L5 Neutral Mechanics
Anterior Base (Deep Sulcus) is on opposite side of Posterior/Inferior ILA
Sacrotuberous ligament ____ on side of _____ ILA
Positive
Negative
Negative
Tight; posterior/inferior
142
Backward Sacral Torsion (Non-Neutral) - LOR, ROL
_____ Seated Flexion Test (opposite side of axis)
_____ Lumbosacral Spring Test (Spring Test)
_____ Sphinx Test (Backward Bending Test)
L5 Neutral Mechanics
Anterior Base (Deep Sulcus) is on opposite side of Posterior/Inferior ILA
Sacrotuberous ligament ____ on side of _____ ILA
Positive
Positive
Positive
Loose; anterior/superior
143
Unilateral Sacral Flexion (Sacral Shear)
____ Seated Flexion Test (side of dysfunction)
____ Lumbosacral Spring Test (Spring Test)
____ Sphinx Test (Backward Bending Test)
Anterior Base (Deep Sulcus) is on same side of Posterior/Inferior ILA or another way of saying this is Posterior Base (Shallow Sulcus is on the same side of Anterior/Superior ILA
Positive
Negative
Negative
144
Unilateral Sacral Extension (Sacral Shear)
____ Seated Flexion Test (side of dysfunction)
____ Lumbosacral Spring Test (Spring Test)
____ Sphinx Test (Backward Bending Test)
Anterior Base (Deep Sulcus) is on same side of Posterior/Inferior ILA or another way of saying this is Posterior Base (Shallow Sulcus is on the same side of Anterior/Superior ILA
Positive
Positive
Positive
145
Forward Sacral Rotation (Neutral) - ROR, LOL
Patient is lying face-down (hug the table) with hips flexed greater than 90 degrees
146
Backward Sacral Rotation (Non-Neutral) - LOR, ROL
Patient lies on their back and hips are flexed less than 90 degrees
147
Unilateral Sacral Flexion ME
| Dx: R USF
Place your left hypothenar eminence on patient’s right ILA
| Ask patient to inhale and hold breath, while you push anterior and superior on the ILA
148
Unilateral Sacral Extension ME
| Dx R USE
Place your left hypothenar eminence on the patient’s right sacral sulcus
Ask the patient to exhale and hold breath, while you push anterior and caudad on the superior sulcus
149
```
Psoas Syndrome
Condition that results from _______
Usually the result of being in a position that allows ___ of the psoas followed by its ____
Examples:
working at a desk or crawlspace
road trips, plane trips
sitting in a soft easy chair or recliner
bending over from the waist for a long period of time
weeding in the garden
trauma (strain)
```
May be precipitated by overuse, such as doing sit-ups with the lower extremities fully extended
Creates a neuromuscular imbalance that results in psoas muscle hypertonicity. Psoas muscle and lumbar spine are affected.
Patient may complain of pain in the thoracolumbar region and/or the anterior hip, thigh, or groin.
hypertonicity/spasm of the psoas muscle
prolonged shortening; sudden lengthening
150
Causes of Psoas Syndrome:
```
Viscerosomatic reflex (ureteral calculi as an example)
Direct irritation (ie, psoas fascia touches the sigmoid colon and ureters)
Ureteral calculi as an example
```
151
Psoas Syndrome: Diagnosis
Patient may stand _______
Motion testing of the affected leg will resist _____
Tender points will be found at Psoas Major muscle (may also find at Psoas Minor and Iliacus if involved) and may be found at contralateral Piriformis muscle.
Special test: ____ will be positive on side of hypertonic psoas muscle
Possibly contralateral piriformis tender point TP - May or may not have sciatic type pain down the opposite leg
Central low back pain - May be significant
slightly flexed at the waist and side-bent toward the dysfunctional side (hypertonic psoas muscle)
hip extension
Thomas Test
152
The key somatic dysfunction initiating or perpetuating psoas syndrome is believed to be a type II (non-neutral) somatic dysfunction (F Rx Sx) usually occurring in the L1 or L2 vertebral unit, where “x” is the side of side-bending of the somatic dysfunction. If this key somatic dysfunction remains, the patient’s symptoms may progress to full-blown psoas syndrome. Osteopathic structural exam findings indicative of this syndrome include:
The key, nonneutral (type II) somatic dysfunction at L1 and/or L2
Sacral somatic dysfunction on an oblique axis, usually to the side of lumbar side-bending
Pelvic shift to the opposite side of the greatest psoas spasm
Hypertonicity of the piriformis muscle contralateral to the side of greatest psoas spasm
Sciatic nerve irritation on the side of the piriformis spasm
Gluteal muscular and posterior thigh pain that does not go past the knee, on the side of the piriformis muscle spasm
153
```
Psoas Syndrome:
Non-neutral L1 and/or L2.
Side bent and rotated to the side ____
Spasm of the piriformis muscle on the ____
Oblique axis sacral dysfunction
Pelvic shift to the ______
Sciatic irritation on ______
```
of the psoas spasm
opposite side of the psoas
opposite side
opposite side
154
```
Special Tests
Hip Drop Test - _____
Trendelenburg Test - ______
FABERE/Patrick Test - ______
Ober Test - _______
Straight Leg Raising (SLR) Test - _________
Contralateral Straight Leg Raising - _______
Bragard Test - ________
Thomas Test - _______
Babinski Reflex - __________
Hoover Test - ________
```
- Thoracolumbar/Lumbar Side-Bending Abnormality
- Gluteus Medius Weakness
- SI joint or hip pathology
- Tensor fascia latae tightness
- Herniated Lumbar Disc (L1-L5, S1)
- Herniated Lumbar Disc (L1-L5, S1)
- Herniated Lumbar Disc (L1-L5, S1)
- Hip Flexion Contracture (Psoas Muscle Hypertonicity)
- Upper Motor Neuron Pathology
- Malingerer
155
Hip Drop Test: Positive
Iliac crest does not drop 20-25 degrees on the non-weight bearing side and there is a poor lumbar spinal curve towards _____ side. A positive test indicates that the lumbar and/or thoracolumbar spine has _____ of the body (ie, the side opposite the positive test)
the weight bearing
difficulty side-bending toward the weight bearing side
156
Sympathetic Innervation:
Ovaries, Testes: ______
Fallopian tubes, Vagina: ______
Uterus and cervix: ______
T10-T11
T11-T12
T10-L2
157
Parasympathetic Innervation:
| Uterus, cervix, vagina, clitoris, walls of the urethra: ____
S2-S4
158
Pregnant Patient - Sympathetic Innervation
| T10-L2 Stimulation
vasoconstriction = poor nutrition and O2 exchange
Increased uterine contraction
Decreased threshold for pain from the uterine body
159
Pregnant Patient - Parasympathetic Innervation
| S2-S4 Stimulation
Vasodilation
Increased relaxation of uterine muscle
Decreased threshold for pain from cervix
160
Direct MFR of Pelvic Diaphragm :
With thumbs medial to the tuberosities gently apply cephalad pressure while maintaining contact with tuberosities at all times
Great for lymphatics/addressing hypertonic pelvic floor musculature
161
Absolute contraindication of OMT during pregnancy
Abruptio placenta
Ectopic pregnancy
Placenta previa
Undiagnosed vaginal bleeding
162
Osteopathic Considerations:
If a patient has been laboring on their back for an extended period of time or if they have undergone cesarean section or other abdominal surgery, consider what type of somatic dysfunctions you might encounter.
*** Note: For example if the sacrum is extended, the base would be posterior and the apex anterior. If you were to do a Muscle Energy treatment on this somatic dysfunction (even though you may never have), you would apply the principles of Muscle Energy by engaging the barrier (which in this case is pushing the base anteriorly). If the patient holds there breath in exhalation this will help move the sacral base anteriorly
ALSO NOTE: If someone has had abdominal surgery recently, don’t put them on their belly (prone)
163
Occipital Condylar Compression
Affecting cranial nerves _______; it can be the cause of poor suckling, swallowing difficulties, colic, emesis/vomiting, hiccups, congenital torticollis.
________ is useful in treating condylar compression
The “most important” or most clinically significant somatic dysfunction which should be addressed in all newborns is occipital condylar compression.
IX, X, XI, XII
OA decompression
164
Reproductive System:
| Parasympathetics S2-S4
Role in erectile dysfunction
165
Sexual Dysfunction:
Impotence: Functional etiology derived from ____
_____ for erection
_____ for ejaculation
S2-S4
parasympathetics
sympathetics
166
Osteopathic Considerations - Renal Physiology Autonomics
| Decreased ureteral peristalsis =
may causes ureteral spasm (uretospasm)
167
Renal Parasympathetics - Vagus Nerve
Affects _____
Superior vagal ganglion sits ______
Inferior vagal ganglion sits ______
Kidney and proximal ureters
jugular foramen
around body of C2
168
Renal Parasympathetics - S2-S4
Affects ____
Via _____
distal ureters and bladder
| pelvic splanchnic nerves
169
Osteopathic Considerations - Renal Physiology Autonomics
Parasympathetic Effects on Renal Physiology
Kidneys:
Ureters:
Bladder:
Kidneys ?
Ureters:
Maintain normal peristalsis
Bladder:
Maintains bladder wall tonicity
Excitatory to detrusor muscle
Inhibitory to trigone muscle
Works in concert with pudendal nerve in micturition
Parasympathetic nerves control bladder wall musculature
Voluntary pudendal nerve controls external urethral sphincter
Sympathetic relaxation of the internal urethral sphincter
Must also occur for voiding to take place
170
Remember indications and contraindications for techniques:
For example if a patient is too young or is not able to follow commands, you can not do techniques such as muscle energy
If a patient has lax ligaments such as Rheumatoid Arthritis or Trisomy 21, you do not want to do HVLA, or ANY type of articulatory techniques in the upper cervical spine. Remember Still Technique is an articulatory technique.
171
Established Patient: 99211
Average min: ___
CC: ___
Exam: ___
5 minutes
Required
None
172
Established Patient: 99212
Average min: ___
CC: ___
Exam: ___
10 minutes
Required
PF
173
```
Established Patient: 99213
Average min: ___
CC: ___
Exam: ___
MDM: ___
```
15 minutes
Required
EPF
Low
174
```
Established Patient: 99214
Average min: ___
CC: ___
Exam: ___
MDM: ___
```
25 minutes
Required
Detailed
Moderate
175
```
Established Patient: 99215
Average min: ___
CC: ___
ROS: ___
Exam: ___
MDM: ___
```
```
40 minutes
Required
*ROS 10+
Exam comprehension
High
```
176
```
Defining level of risk:
Minimal ____
Self-limited/Minor ____
Low severity ____
Moderate severity ____
High severity ____
```
```
Could see RN
Not likely
Low risk
Increased probability
High risk
```
177
```
98925 OMT to ____ regions
98926 OMT to ____ regions
98927 OMT to ____ regions
98928 OMT to ____ regions
98929 OMT to ____ regions
```
```
1-2
3-4
5-6
7-8
9-10** the max amount of regions you can treat with OMT in a single encounter
```
178
Goal of ME in innominate SD treatment is to _____
restore joint motion
