Manual Examination/ Treatment Techniques

Question 1

Dx- C3-7 Supine FRS

Answer 1

1. Patient is supine on the table with the operator sitting at the head of the table.
2. Operator’s index and middle fingers of each hand contact the pillar of the superior vertebra of the motion segment being tested.
3. Operator’s palms and thenar eminences control the patient’s
   head and upper cervical spine.
4. Operator’s finger contacts translate the vertebra anteriorly to the backward-bending barrier (lift the fingers toward the ceiling).
5. With the palm and the thenar eminence controlling the patient’s head and upper cervical, the operator introduces translation from right to left, sensing for resistance to move- ment at his index fingers. If resistance is encoun- tered, the motion restriction is backward bending, right-side bending, and right rotation (flexed, rotated, and side bent left [FRSleft]). Something interfered with the capacity of the right facet to close.
6. With the palm and the thenar eminence controlling the patient’s head and upper cervical, the operator introduces translatory movement from left to right sensing for resistance to movement at his index fingers. If resistance is encountered, the motion restriction is backward bending, left- side bending, and left rotation (FRSright). Something interfered with the left facet to close.

Question 2

Dx- C3-7 Supine ERS

Answer 2

1. Patient is supine on the table with the operator sitting at the head of the table.
2. Operator’s index and middle fingers of each hand contact the pillar of the superior vertebra of the motion segment being tested.
3. Operator’s palms and thenar eminences control the patient’s head and upper cervical spine.
4. Operator flexes the head and neck down to the segment under examination.
5. With the palm and the thenar eminence controlling the patient’s head and upper cervical, the operator introduces translation from right to left, sensing for resistance to movement at his index fingers. If resistance is felt, the motion restric- tion is forward bending, right-side bending, and right rotation (extended, rotated, and side bent left [ERSleft]). Something has interfered with the capacity of the left facet to open.
6. With the palm and the thenar eminence controlling the patient’s head and upper cervical, the operator introduces translation from left to right sensing for resistance to movement at his index fingers. If resistance is encountered, the motion restriction is forward bending, left-side bending, and left rotation (ERSright). Something interfered with the capacity of the right facet to open.

Question 3

Dx - Atlantoaxial (C1,2) Supine Rotation Restriction

Answer 3

Position: patient is supine, PT standing at head of table
Action: 1. PT’s hands hold each side of the patient’s head with the index fingers on posterior arch of atlas (just inferior to occiput) flex patient’s neck 45 degrees (tightening ligamentous flavum to localize AA
2. Rotate to left and right, feel for restrictions
Pathology: pt has restriction in left rotation = positional diagnosis is AA rotation right

Question 4

Dx - Occipitoatlantal (O-A) Supine Extension Restriction

Answer 4

Position: patient is supine, PT head of table
Action: 1. PT grasps sides of patient’s head with index finger monitoring along posterior arch of C1(atlas) 2. place into slight extension, translate left and right feel for restrictions
-Condyles will glide anterior with extension
-With extension, side bending right rotation left = right condyle glides anteriorly
Pathology: flexion legions, left translation restriction = limited in extension, right side bending, left rotation = FSlRr (right condyle is not moving correctly, can’t move anteriorly)

Question 5

Dx - Occipitoatlantal (O-A) Supine Flexion Restriction

Answer 5

Position: patient is supine, PT head of table
Action: 1. PT grasps sides of patient’s head with index finger monitoring along posterior arch of C1(atlas)
2. place into slight flexion, translate left and right feel for restrictions
-Condyles will glide posterior with flexion
-With flexion, side bending left rotation right = right condyle glides posteriorly
Pathology: extension legions, right translation restriction = limited in flexion, left side bending, right rotation = ESrRl (left condyle is not moving correctly, can’t move posteriorly)

Question 6

Rx – FRS left C5,6

Answer 6

muscle energy technique

Position: patient is supine, PT head of table
Action: 1. PT’s index finger on right articular pillar of C6
2. apply extension to C6 by applying P-A force on C6, translate to left, stop when feeling translation occur at finger with slight rotation to right
3. ask patient to gently contract muscles to look down to left shoulder (flexion side bend rotation to left)
4. 5-7 sec contraction, 3 second relax, apply more P-A force(extension) translation and rotation
Neuromuscular reeducation – from this position ask patient to hold position of extension side bend and rotation right while you try to pull them in opposite direction(isometric)
then have then slowly let you win (isotonic)
then have them fight you back into extension right side bend/rotation(concentric)

Question 7

Rx - ERS left C2,3

Answer 7

muscle energy technique

Position: patient is supine, PT head of table
Action: 1. PT’s left hand Reach under spine with index finger localizing to right joint line of C2-C3, thumb placed on left articular pillar of C2
2. support head with right head
3. translate left with index finger and apply slight right rotation
4. ask patient to extend, side bend and rotate left against resistance
5. 5-7 sec contraction, 3 second relax, apply more further flex, translate and rotate
Neuromuscular reeducation – (isometric) (isotonic) (concentric)

Question 8

Rx – Restricted Atlas Rotation Left

Answer 8

muscle energy technique

Position: patient is supine, PT head of table
Action: 1. Place fingers inferiorly to occiput, over arch of atlas
2. Flex head 45 degrees to lock out C2-C7
3. Rotate head left to barrier, feel arch of atlas come back into left index finger
4. bring right hand on right side of their face to resist right rotation
5. 7 sec contract, 3 relax slowly increase left rotation

Neuromuscular reeducation – isometric, eccentric, concentric

Question 9

Rx - Restricted Left O-A Extension (FSrRl)

Answer 9

muscle energy technique

Position: patient is supine, PT head of table
Action: 1. Left hand Place side of index finger along the space between occiput and C1 (cervicocranial junction)
2. Right hand controls patient’s chin, index in front of ramus, middle under and forearm on side of head
3. Provide slight extension(15), translate to right (for left side bending and right rotation)
4. have patient try to side bend back to right against resistance 7sec 3 sec contraction
5. add more extension, translation
6. can ask patient to also chin tuck with side bending
Neuromuscular reeducation – ask pt to fight chin tuck, then have them let you win, then concentric extension

Pathology: motion restricted extension, left side bending right rotation

Question 10

Rx - Restricted Right O-A Flexion (ESrRl)

Answer 10

muscle energy technique

Position: patient is supine, PT head of table
Action: 1. Left hand Place side of index finger along the space between occiput and C1 (cervicocranial junction)
2. Right hand controls patient’s chin, index in front of ramus, middle under and forearm on side of head
3. provide slight flexion, translate right (left side bending rotating right)
4. resist back into extension
5. continue MET
Neuromuscular reeducation – same as above

Pathology: motion restricted flexion, left side bending right rotation

Question 11

Dx – T1–5 Type I and II Dysfunction

Answer 11

Position: pt seated in chair, with you standing behind
Action: 1. With patient’s neck in neutral→ Start from C7→ go to SP of T1→ travel lateral to 1st valley→ over spinalis muscle→ 2nd valley (between spinalis and longissimus) with index finger, find on both sides of SP
2. perform finger sweep down 2nd valley to find any “tootsie roll signs” (feels like a speed bump) (sign of dysfunction)
3. now with thumbs move lateral over longissimus and into 3rd valley→ palpate posterior aspect of transverse processes, starting at T1
4. check to see which thumb is more anterior (if left thumb is and right is posterior→ rotated to the right), can’t diagnosis yet
5. keep checking each level down to T5
6. after neutral, have patient flex neck separately for each segment, run though assessment again
7. perform assessment again with patient doing extension (chin tuck)
Pathology: In neutral→ T1 left anterior right posterior→ rotated right
In flexion→ T1 symmetric→ may be FRS right based off neutral finding, but can’t know until all 3 tested In extension→ T1 asymmetric→ patient has Type II (one segment) FRS right @ T1

Question 12

Rx – ERS left T4,5

Answer 12

Muscle energy technique

Position: patient seated, with you standing behind and to the right
Action: palpate the interspinous space of T4,5 with left index finger and left T4 TP with left middle finger Right hand on head, flex neck slightly and have patient slouch to achieve flexion of T spine
Translate patient left (for side bending right) can use your torso
Have patient fight extension, left side bending/rotation (ask patient to look over left shoulder)
Further flex and translate left

Pathology: left facet stuck closed

Question 13

Rx – FRS left T2,3

Answer 13

Muscle energy technique

Position: patient seated, you behind and to the left
Action: palpate interspinous space of T2,3 with right index finger, right middle finger slightly above right TP of T2
Provide slight P-A force from palm and extend T spine, place left hand on head, swan neck hold (forearm is on the side of head and elbow over shoulder) flex elbow and wrist at 90 degrees)
Slight rotation to right & P-A for extension and side bending to right
Ask patient to look down to their left hip (resist flexion, left side bending/rotation)
Further rotation, P-A and side bending to right

Pathology: right facet stuck open

Question 14

Rx – T1- 5 Neutral, Group Dysfunction (NSrRl)

Answer 14

Position: patient seated, stand behind them
Action: bend your right leg up so your knee is under their right axilla, have them rest their right arm on your knee
Palpate with left thumb, left side of SP of T2 (@ apex of curver)
Right arm swan neck hold
Use your body and leg to translate patient to the right (left side bend) and rotate neck right
Have patient side bend to the right and rotate left against resistance
Further translate right and rotation right

Pathology: patient restricted with left side bending and right rotation

Question 15

Dx – T6–12 Type I and II Dysfunction

Answer 15

Position: patient seated, with you behind
Action: palpate to T6, go to second valley and perform skin drag test with index fingers for any “tootsie roll signs”
Place thumbs on both TPs, have patient place hands in lap to get scapula out of the way
Check for any asymmetry in TPs
For flexion have them slouch and flex neck
Can also reassess neutral in prone
For extension have them go into prone, have pt place hands under chin to prop up into extension
Pathology: in neutral→ T7 left posterior right anterior → rotated left
In flexion→ T7 asymmetric → ERS left (can’t flex, side bend and rotation to the right)
In extension→ symmetric

Question 16

Rx – ERS right T8,9

Answer 16

Position: patient seated, you behind and to the left
Action: palpate interspinous space of T8,9 with right index finger and right TP of T8 with right middle finger
Have patient bring their left hand over to their right shoulder then place your hand over their hand/right shoulder
Your left axillary contact on their left shoulder
Localize with a little A-P/ flexion so you’re at the joint
Translate to right (side bend left) and rotation to left
Ask patient to side bend right and rotate right and extend
Further flex, translate and rotate

Pathology: restricted in flex, left rotation and left side bending

Question 17

Rx – FRS right T8,9

Answer 17

Position: patient seated, with you behind
Teach patient to shift onto each buttock, not lift
Action: phase I – fixing a neutral correction
palpate interspinous space of T8,9 with right index finger and right TP of T8 with right middle finger
Ask patient to shift over to left buttock (left translation = right side bend) add left rotation
Ask patient to rotate right against resistance
Further side left and rotate left

Phase II – hold patient in rotated position
Ask patient to shift to right buttock (translate right) and give P-A force with fingers
Patient should be in extension left side bending and rotation
Ask patient to right side bend and rotate right against resistance
Further shift right (side bending left), P-A (extension), rotation left

To finish technique use hold hand to take patient into full extension (P-A force at T9)
Wrap your arm around their front and grab right shoulder, have patient try to flex against resistance

Pathology: restricted in extension, side bending and rotation to the left

Question 18

Rx – T6-12 Neutral, Group Dysfunction (NSlRr)

Answer 18

Position: patient seated with feet resting on something, with you behind to the left
Action: have patient bring their left hand to their right shoulder, weave your left arm through their arm to their right shoulder
Palpate right lateral aspect of SP of T7
Translate patient towards you, (left translation=right side bending) rotate left (to segment you’re working at)
Ask patient to side bend left and rotate right against resistance
Further translate left (right side bend) and rotate left

Pathology: restricted in neutral, side bending right and rotation left

Question 19

Dx – L1-5 Type I and II Dysfunction

Answer 19

Position: patient prone
Action: palpate PSIS with thumbs→ S2→ lumbosacral junction
Can gap L5,S1 with a P-A on the sacrum to double check if you’re on the junction
Assess symmetry of TPs with thumbs
Continue with patient in sphinx position (extension), assess TPs
Continue with prayer position (flexion), assess TPs
Can also do flexion in seated position (feet supported)

Question 20

Rx – ERS left L4,5

Answer 20

Position: patient seated, stand in front on their left
Action: patients left hand on their right shoulder as well as your left hand on their right shoulder
With your axilla/coracoid process on their left shoulder
Right middle finger interspinous space of L4,5 and right index on left L4 TP
Ask patient to slouch to feel localization to the segment
Have patient’s right arm hang towards the floor
Shift the patient left for right side bending and right rotation local to the segment
Have patient side bend towards you (left) can also extend and rotate left
have patient try to look over left shoulder
Further flexion, translation and rotation
From the last position fully flex patient, and have them try to extend with resistance
Pathology: restricted in flexion, right side bending and rotation

Question 21

Rx – FRS left L3,4

Answer 21

muscle energy technique

Position: patient seated with feet on chair, stand behind to their right
Action: first teach patient how to shift from one buttcheek to another
Palpate L3,4 interspinous space with left index and left L3 TP with left middle finger
Your right hand on their right shoulder

Phase 1 - Have patient shift on right buttock (right translation left side bend) and then rotate right until localization
Ask patient to rotate left, resist, then further rotate right

Phase 2 – apply P-A pressure at palpation L3,4 (extension)
ask patient to shift to left buttock (left translation right side bend) and rotate to the right
ask patient to flex and rotate left with resistance
further ext, rotate and side bend to right

Phase 3 – make a fist with your left contact hand, and place at level of L4, P-A and place into bilateral extension
ask patient to flex with resistance, further extend and repeat

Question 22

Rx - FRS left L4,5

Answer 22

Position: patient sidelying on left. Stand in front of patient. Knees and feet are together and shoulder and pelvis perpendicular to table (being sidelying left forces patient to be side bent right)
Action: place left hand over L4,5 and right hand reach under to L4,5 translate forward for extension
Grab around left shoulder using right hand and bring into extension
Switch hand palpation, right on L4,5 and left extends back from legs
push down on their right shoulder for right rotation, have patient grab table with right hand to maintain rotation
right hand palpates L4,5 and left grabs under right knee and abduct to place patient into more right side bending
ask patient adduct with resistance, further abduct leg (right side bend)

Question 23

Rx - L1-5 Neutral, Group Dysfunction (NSrRl)

Answer 23

Position: patient seated, stand on left in front
Action: patient holds right shoulder with left hand
Your left hand on their right shoulder and your axilla on their left shoulder
Palpate right thumb at apex of convexity (in this case L3)
Translate patient away onto right buttock (right translation for left send bending & slight right rotation) - Keep patient in neutral
Ask patient to side bend right with resistance, further translate (more left side bend) and rotate right
Pathology: type 1 dysfunction between L1-L5 (side bent right, rotated left aka easy normal left, named for the side of rotation) want patient to improve motion in side bending left and rotation right

Question 24

Dx – Standing Flexion Test

Answer 24

• pt stands with PT standing behind pt
• PT contacts PSISs with thumbs
• pt asked to segmentally flex forward and bring hands to the floor
• PT monitors each PSIS for symmetry

POSITIVE if one goes first or further

could be tight QL bringing one side up first, tight HS holding other side down, etc

PT must be eye level with the PSISs

Question 25

Dx – One-Legged Stork Test (Gillet)

Answer 25

Position: patient standing with you behind
Action: palpate PSIS and S2 on side you’re testing
Ask patient to flex hip past 90 on side of palpation while holding on to the table
PSIS should go inferior and lateral
Pathology: assesses posterior iliac rotation. When looking at the sacrum, the side of sacral base dysfunction will always move first.
Ex. L/L forward sacral torsional motion, during test the right PSIS will move first and forward. The right sacral base is the side of dysfunction because it is stuck forward.
The side of the dysfunction sacral base will prematurely pull the innominate forward causing a positive test.

Question 26

Dx – Sitting Flexion Test/ILA exam. in flexion

Answer 26

Position: patient seated, with you seated behind them
Action: palpate PSIS with thumbs, assess for symmetry
Come below PSIS, slack some skin
Patient places hands behind head and elbows in front
Segmentally flex neck and spine down, assessing PSIS
-In flexed position, palpate ILAs and assess symmetry
Pathology: asymmetry with a PSIS moving first and further compared to the other side

Question 27

Dx – Prone ILA Exam

Answer 27

Position: patient prone
Action: palpate ILAs with thumbs, start in neutral, Assess for symmetry
come inferior on ILA, this checks for shears, assess for symmetry again
Place patient in sphinx position to assess ILA in extension
Pathology: if ILA is asymmetrical could be unilateral legion

Question 28

Dx – Prone Sacral Base Exam

Answer 28

Position: patient prone
Action: palpate PSIS, come medially and cranial to get on the sacral bases
Assess symmetry of sacral bases, if one is more “deep” than the other
Go to L5 then the posterior arch (lamina) and assess symmetry

Question 29

Dx – Prone Prop ILA and Base Exam

Answer 29

aka Four Point Sacral Motion

Position: patient prone
Action: thumbs are palpating the posterior aspect of the ILAs and index fingers on the sacral bases
Ask patient to take a deep breath in and out, assess movement
With inspiration thoracic spine extends and lumbar flexes
Inspiration = ILAs should go forward, sacral bases should counter nutation
Expiration = ILAs should go backward, sacral bases should nutation
Place patient in sphinx position, assess again, as well as symmetry of inferior ILA, PSIS and sacral bases

Question 30

Dx – Lumbar Spring Test

Answer 30

Position: patient prone
Action: palpate to L5,S1 junction, place heel over junction
Apply a P-A pressure, looking for springy movement
Pathology: if no spring movement = sacrum is not nutating and lumbar L5 is not extending
Positive if it is rigid, if there is resistance with the P-A (could mean L5 is flexed or sacrum is counter nutated)

Question 31

Rx – Left Unilateral Sacral Flexion

Answer 31

Position: patient prone stand on their left
Action: Left hand palpates left sacral base
15° abduction left leg – releases pressure off the SI joint
Slight IR left leg – innominate rotates and gaps posterior portion of the SI joint
Right pisiform palpates left ILA, hand should face about 10 oclock, if patients head is 12 oclock
Ulnarly deviate right hand to push up the sacrum (go to 12 oclock)
Apply P-A on ILA to bring the sacral base backwards
Maintain your force, ask patient to take a deep breath
As patient exhales, maintain pressure, slowly getting to new barriers with each breath repeat 3 times - Reassess left sacral base
Pathology: a force knocked sacrum forward and down, our treatment = shear it up and knock it back - Unilateral won’t correct in extension or flexion, will always show

Question 32

Rx - Right Unilateral Sacral Extension

Answer 32

Position: patient prone in sphinx, stand on their right
Action: right hand monitors right sacroiliac joint
Left hand moves right leg into 15 of abduction and slight ER
Ask patient to go into sphinx position (will cause sacral bases to nutate/go forward)
Right pisiform makes contact with right sacral base, hand should face 5 oclock, if patient’s feet are 6 oclock
Correct the shear, ulnarly deviate hand to push sacral base down (go to 6 oclock)
Left hand palpates right ASIS
Patient takes deep breath in, on exhalation follow it down with a P-A into nutation to bring sacral base back forward
At full exhalation, ask patient to try and contract ASIS into your left hand, hold, relax, and try to shear the innominate towards the ceiling (with left hand)
Repeat cycle
Pathology: a force knocked the sacrum up and back

Question 33

Rx – Left on Left Forward Sacral Torsion

Answer 33

Position: patient prone, stand on right
Action: palpate right sacral base with right index
Have patient flex knees to 90
Place patient into sims position, their pelvis should face you, dysfunction sacral base will be facing the ceiling
pelvis needs to be perpendicular to table
Rest their knees on your thigh. Their legs must stay together
Also slightly flex patients trunk, Your left hand holds their feet
Gap L5,S1 segment by bringing their feet towards the floor
Resist their feet coming up, further side bend and flexion x3
Pathology: you’re correcting the right sacral base, by causing R/L backward sacral torsion
This diagnosis will get better in prone prop and worse in flexion

Question 34

Rx – Right on Left Backward Sacral Torsion

Answer 34

Position: patient sidelying with side of dysfunction facing up. right side is up. Stand in front of patient
Action: get local to L5,S1 junction. Left hand comes over and right hand comes under. Pull patient into extension
Keeping left hand on junction, right hand moves top spine into extension
Then rotate their right shoulder down and let them hold onto the table to maintain rotation
Pelvis needs to stay perpendicular to table
Last bit of rotation comes from lawn mower technique. Pull their left shoulder towards you
Lastly, extend the legs back for last bit of extension in spine
Bend patient’s top leg so that their foot rests in the popliteal space of the bottom leg and their top knee is slightly hanging off the table (slightly different from picture in textbook)
With your left hand place on top knee, ask patient to bring knee to ceiling with resistance
Further bring leg down x3
Slowly bring patient out of this position, keep and hold both of their legs together and provide some lumbar flexion
Pathology: the right sacral base is not coming forward with lumbar extension