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OS4 exam 1 > FPR OSCE > Flashcards

FPR OSCE Flashcards

1
Q

1a. Hypertonic muscles for cervical (superficial muscle hypertonicity)

A
  • Pt supine with head and neck off table
  • Doc at head of table supporting pt’s head
  • Monitor hypertonic tissues with 3rd finger
  • Slightly flex head and neck forward to flatten cervical curvature
  • Apply gentle axial compression (<1 lb pressure) on occiput towards feet
  • While maintaining flattened lordosis and compression, extend head/neck and sidebend to same side of hypertonic muscles (shortening and relaxing muscles being treated.
  • Hold for 3-4 secs waiting for tissue relaxation. Return to neutral and release compression. Reassess
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2
Q

1b. Segmental dysfunction for cervical. Example C4 F RrSr

A
  • Pt supine with head/neck off table.
  • Doc at head of table supporting pt’s head with one hand grasping neck with index finger and thumb on articular pillars of affected segment
  • With other hand at vertex of pt’s head, slightly flex head and neck to flatten cervical curvature (flexion of OA)
  • Apply gentle axial compression, down vertebral axis towards feet
  • While maintaining flattened lordosis and compression, move segment into its ease of motion (indirect barrier of flexion/extension, rotational, and sidebending component)
  • Hold for 3-4 seconds waiting for tissue creep, return to neutral, and release compression. Reassess.
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3
Q

1c. Hypertonic muscles for thoracic. Example T7

A
  • Pt seated. Doc standing behind pt on side of dysfunction.
  • Monitor at site with one hand.
  • Place other arm on pt’s shoulder on side of dysfunction, with forearm resting behind pt’s neck
  • Instruct pt to sit upright to flatten kyphosis (may lift chest up with shoulders back)
  • While maintaining flattened kyphosis, apply downward compression and side-bend down to monitoring finger
  • Hold 3-4 seconds waiting for tissue creep. Return to neutral and release compression. Reassess
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4
Q

1d. Segmental dysfunction seated for thoracic. Example T4 E RlSl

A
  • Pt seated. Doc standing behind pt on side of dysfunction. Monitor at PTP
  • Ask pt to sit as straight as possible, lifting chest to flatten thoracic kyphosis
  • Reach across pt’s anterior or posterior aspect of chest for control of pt’s trunk
  • While maintaining flattened kyphosis, apply downward axial compression and put pt into ease of motion (indirect barrier)
  • Hold for 3-4 seconds for tissue creep. Return to neutral and release compression. Reassess segmental motion.
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5
Q

1e. Segmental type II dysfunction, prone technique for thoracic. Example T3 E RrSr

A
  • Pt prone (place pillow under pt if necessary to flatten thoracic curvature)
  • Doc standing beside table, opposite dysfunction. Monitor PTP with cephalad hand
  • With caudad hand, grasp pt’s shoulder over acromion process and pull caudally to induce sidebending and posteriorly to induce rotation
  • Hold for 3-4 seconds. Return to neutral. Reassess
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6
Q

1f. Hypertonic muscles for lumbar. Example left lumbar

A
  • Pt prone with pillow under abdomen to flatten curvature
  • Doc on same side of dysfunction
  • Monitor hypertonic muscles with cephalad hand
  • Place knee on table at pt’s hip to use as fulcrum
  • Using caudad arm, pull pt’s legs towards you, inducing sidebending to same side until motion felt at tissues
  • Cross pt’s contralateral leg over the other to rotate, increase rotation by pulling posteriorly at pt’s contralateral thigh or ASIS (extending leg) and externally rotate until torsional motion is felt at monitoring hand (pull leg towards doc)
  • Hold 3-4 secs waiting for tissue creep, return to neutral. Reassess
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7
Q

1h. Extension dysfunction, alternative for lumbar. Example L4 E RlSl

A
  • Pt lateral recumbent with PTP up
  • Doc behind pt, monitor PTP
  • Grasp top knee and abduct leg until motion is felt at monitoring hand. Lower leg or ankle may rest in doc’s antecubital fossa
  • Internally rotate hip and extend until motion is felt
  • Hold 3-4 seconds for tissue creep. Return to neutral. Reassess.
  • God for pts who cannot tolerate lying prone (pregnancy, psoas syndrome, post-surgical)
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8
Q

1i. Flexion dysfunction, prone for lumbar. Example L4 F SsRr

A
  • Pt prone at edge of table with pillows under abdomen to flatten curvature
  • Doc seated next to table on side of PTP and monitor PTP
  • Grasp pt’s ipsilateral knee and flex hip until motion is felt at monitoring hand
  • Adduct and internally rotate/externally rotate at hip until motion is felt
  • Hold 3-4 seconds for tissue creep. Return to neutral. Reassess
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9
Q

1k. Piriformis muscle

A
  • Pt prone with pillow under abdomen.
  • Doc seated beside table on side of dysfunciton. Monitor at piriformis insertion at greater trochanter.
  • Flex knee and drop pt’s knee and thigh off table, allowing hip to flex forward until motion is felt at monitoring hand
  • Adduct/abduct and internal rotate knee until motion is felt
  • Induce compression at knee toward monitoring hand, feeling for tissue creep
  • Hold for 3-4 secs. Return to neutral. Reassess
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10
Q

1l. Gluteus maximus muscle (palpated in middle of muscle or directly inferior to iliac crest)

A
  • Pt prone with pillow under abdomen
  • Doc seated on side of dysfunction. Monitor dysfunction (usually at iliac crest)
  • Flex pt’s knee to 90 degrees, bring ipsilateral hip and knee into full abduction to rest knee on doc’s thigh farthest from pt
  • Raise heel off floor until motion is felt at monitoring hand. Induces extension
  • Doc pushes pt’s knee externally or pulls pt’s ankle medially, causing external rotation at hip
  • Hold for 3-4 seconds for tissue creep. Return to neutral. Reassess.
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11
Q

1m. Anterior rib cage and costochondral dysfunctions. Example Rib 4 left, anterior

A
  • Pt seated. Doc behind pt.
  • Doc places arm opposite side of dysfunction around front of pt and monitors at dysfunction
  • Ipsilateral hand monitors at cervicothoracic junction with left arm resting on pt’s shoulder
  • Instruct pt to sit upright, flattening thoracic kyphosis
  • Doc compresses downward through spine
  • While maintaining kyphosis and compression, flex pt forward until motion is felt at monitoring hand (may need to flex neck as well)
  • Sidebend pt toward dysfunction (may need to rotate)
  • Hold for 3-4 seconds. Return to neutral. Reassess
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12
Q

1n. Posterior rib dysfunctions, seated. Example rib 5 right posterior

A
  • pt seated at edge of table. Doc at side of dysfunction and monitor posteriorly at dysfunction
  • Pt instructed to sit upright, flattening thoracic kyphosis
  • Place arm anteriorly across pt’s shoulders
  • While maintaining flattened kyphosis, compression downward on shoulders and sidebend to side of dysfunction. Doc’s elbow used to induce posterior rotation down to level of dysfunction
  • Hold for 3-4 seconds waiting for tissue creep. Return to neutral. Reassess.
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13
Q

Define spinal facilitation

A

Maintenance of pool of neurons (premotor neurons, motor neurons, or preganglionic sympathetic neurons in spinal cord) in a state of partial or subthreshold excitation.
In this state, less afferent stimulation is required to trigger discharge of impulses.
Facilitation may be due to sustained increase in afferent input, aberrant patterns of afferent input, or changes within affected neurons themselves or their chemical environment.
Once established, facilitation can be sustained by normal CNS activity

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14
Q

___ give rise to 2 classes of sensory neurons that enter through posterior horn and terminate

  • immediately on gray matter
  • or terminate at higher levels of nervous system (brain stem, cortex, etc)
A

Dorsal sensory neurons

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15
Q

What are the types of dorsal sensory neurons?

A

Ia: primary afferent, most sensitive to rapid change
II: Secondary afferent, sensitive to change in length
Ib: only afferent nerve associated with golgi tendon organ

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16
Q

__ give rise to 2 primary nerve types that exit anterior horn to innervate skeletal muscle. 2 types?

A

Ventral motor neurons
Alpha motor neurons stimulate large fibers
Gamma motor neurons innervate small fibers - intrafusal fibers

17
Q

Describe muscle spindles

A
  • Intrafusal mechanoreceptors between skeletal fibers in belly of muscle
  • Composed of specialized intrafusal fibers (nuclear bag fibers and nuclear chain fibers)
  • innervated by both sensory and motor nerve fibers
  • Sends info about muscle length and rate of change in muscle length
18
Q

Describe the purpose of muscle spindles and what happens with stimulation and stretching

A
  • Purpose: prevent tissue disruption and has more interest in protecting muscle belly
  • Stimulation of muscle spindles occurs with lengthening of whole muscle or with contracting endpoints of intrafusal fibers
  • Stretching the muscle spindle increases rate of firing, and shortening decreases rate of firing
  • Even in neutral, there is baseline firing
19
Q

Describe golgi tendon reflex

A
  • Sends info about muscle tension or rate of change in tension
  • Prevents tissue disruption/tearing of muscle or avulsion of tendon from boney attachment and has more interest in protecting tendon
  • Mech: Autogenic inhibition/negative feedback loop
  • Extreme tension -> activate GTR -> inhibitory effect in spinal cord -> muscle relaxation
  • Abnormal functioning of either GTR or muscle spindle can lead to abnormal muscle function/tone
20
Q

Describe gamma motor neurons

A
  • Efferent neuron which innervates muscle spindles.
  • Plentiful in body and can comprise 70% of motor neurons exiting spinal cords in some regions
  • Keep steady state on spindle
  • One disadvantage to always being on is that system is vulnerable to dysfunction
21
Q

Describe the primary functions of Gamma motor neurons

A
  • Gamma loop: Stretch/contraction of muscle activates gamma motor neurons -> causes intrafusal fibers to contract -> stretches muscle spindle -> activates sensory ending -> innervates and excites alpha motor neuron -> muscle contraction (responsible for maintaining postural tone)
  • Keeps muscle spindle taut: Cause intrafusal fibers to contract sufficiently to stretch muscle spindle towards threshold -> increases sensitivity of muscle spindle apparatus to stretch
22
Q

Describe gamma loop dysfunction/gamma gain dysfunction

A

Causes:
Firing too frequently -> prolonged stimulus
Stretch reflex: sudden stretch of muscle -> stretching of muscle spindle -> activation of innervated alpha motor neuron -> muscle contraction -> spasm
-Sensory signals also travel to higher centers of CNS, which cannot interpret them -> respond with gamma stimulation which maintains spasm (causing tenderpoint)

Even if muscle goes back to neutral or actively to a shortened position, abnormal gamma motor neuron stimulation can continue stretch reflex, maintaining spasm

23
Q

Define FPR

A

Modification of indirect myofascial release treatment developed by Stanley Schiowitz, DO.
Restricted region of body is placed into neutral position to diminish tissue and joint tension in all planes
Then activating force (compression/torsion) is added

Primary goal: Reduce abnormal muscle hypertonicity (superficial and deep) and restore lost motion to a restricted articulation

24
Q

Describe the basic steps of FPR

A
  1. Monitor: at hypertonic muscles and/or over inferior articular facet of dysfunctional segment
  2. Modify sagittal posture: Flatten curve or place region in neutral position
  3. Add facilitating force: Compression or torsion (sometimes traction)
  4. Move into freedom of motion: Large muscles are shortened. Segmental somatic dysfunctions are passively placed into freedoms of motion
  5. Tissue relaxation: Hold 3-4 seconds monitoring for tissue relaxation or release of dysfunction.
  6. Neutral: Return to neutral and release compression
  7. Reassess: Palpate for TART changes, ROM, or segmental motion
25
Q

Indications for FPR

A

Acute or chronic somatic dysfunctions (can be used primary treatment or in conjunction with others)
Muscle spasticity

26
Q

Relative contraindications

A
  • If pt cannot voluntarily relax or tolerate position (may use alternate positioning)
  • Severe osteoporosis or joint instability
  • If pt experiences radicular pain, then repositioning or traction may be attempted
  • Fracture or disc herniation in region being treated
  • Not advisable across recent wounds (surgical or otherwise) or fractures less than 6 weeks old
27
Q

Use caution with FPR

A 
Osteoporosis
Malignancy 
Rheumatological disorders
Congenital malformations
Stenosis
28
Q

Absolute contraindications

A

Lack of pt consent or cooperation

29
Q

Theory of somatic dysfunction

A

SD is initiated or maintained by increased activity in gamma motor neurons of muscles or particular segment
Gamma motor system stimulates muscle spindles
Overall result is increased tension in muscle, even in neutral position

30
Q

Theory of FPR tx of SD

A

Positioning muscle in neutral position (with respect to F/E) results in

  • inverse spindle output, which eliminates afferent excitatory input to spinal cord through group Ia and II fibers. Tension and hypertonicity of extrafusal muscle fiber is reset. Positive influence upon proprioceptive and nociceptive activity
  • Unloading the joint, which enables rapid response to 3-plane therapeutic position (shifted neutral)

Initial response is soft tissue, then articular

OS4 exam 1 (3 decks)

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