OMM Spring 2020 Exam 1 Flashcards
The sacrum is viewed as part of the _______ and the paired inominates are viewed as part of the ________
In the human infant, the pelvis is narrow and unsupportive, but as we begin to walk, the pelvis broadens and tilts while the sacrum descends into its articulation with the ilia. Also, the lumbar curve of the lower back develops.
Sacrum: vertebral axis
Inominates: Lower extremities (x2)
The pelvic inlet/brim is composed of
a. sacral promontory
b. iliopectineal line
c. superior border of pubic symphysis
d. left rami of pubic arch
A-C
NOTE: pelvic outlet is confined by the pubic symphysis, right and left rami of the pubic arch, ischial tuberosities, sacrotuberous ligaments and tip of the coccyx
Difference between male and female pelvis includes:
The male pelvis is sturdier with more height, while the female pelvis grows more ______ in diameter. It is larger with a more rounded inlet and outlet, and has a larger _______ angle.
Female: transverse growth, larger infrapubic angle
*greater distance between ischial tuberosities and coccyx
What is the most common pelvic type?
Gynecoid
The inominates of the pelvis are composed of three main parts:
- Ilium
- Ischium
- Pubis
The ilium accounts for the width of the _____, while the ischium is where the weight falls while seated.
Ilium: widgth of the hips
**all 3 unite in early adulthood at the acetabulum (triangular suture)
A fibrocartilaginous joint that joins the two inominate bones ANTERIORLY. The muscular forces can cause rotation at the symphysis along the transverse axis.
Pubic Symphysis
Bilateral L-shaped joints that join each innominate to the sacrum.
Sacroiliac joint
*injections for inflammation (arthrodial joint)
NOTE: sacral side = hyaline cartilage; ilial side = fibrocartilage
The Pelvis is surrounded by:
- anterior sacroiliac ligaments
- interosseous sacroiliac ligaments
- posterior sacroiliac ligaments
- accessory ligaments (sacrotuberous, sacrospinous, iliolumbar)
Which of the above are true ligaments?
- anterior sacroiliac ligaments
- interosseous sacroiliac ligaments
- posterior sacroiliac ligaments
NOTE:
ventral: iliolumbar, ant. sacroiliac
dorsal: sacrospinous, sacrotuberous, post. sacroiliac
Motions within the pelvic girdle are numerous and occur around various axes
- sacral
- inominate (ilia)
- pubic
True/False: Dysfunction of motion around any of these axes may be reflected by muscle spasm, back or pelvic pain, gait disturbance/leg pain, changes in or creation of compensatory patterns, and/or increased energy demands.
True
Fred Mitchell describes 3 transverse axes and 2 oblique axes. Transverse axes include:
- Superior transverse axis (STA)
- Middle transverse axis
- Inferior transverse axis
This axis is located approximately at S2. Flexion/Extension is associated with respiration and cranial sacral motion.
Superior transverse axis
NOTE:
Inhale: sacral base posterior into sacral extension.
Exhale: moves ant. into flexion
Fred Mitchell describes 3 transverse axes and 2 oblique axes. Transverse axes include:
- Superior transverse axis (STA)
- Middle transverse axis
- Inferior transverse axis
This axis is located between the upper and lower limbs of the SI joint. This is the site where postural motion (flexion/extension) occurs.
MIddle transverse axis
NOTE:
-bend forward: sacral base moves ant.
(at terminal flexion, sacrotuberous lig. becomes tight and base moves posteriorly)
Fred Mitchell describes 3 transverse axes and 2 oblique axes. Transverse axes include:
- Superior transverse axis (STA)
- Middle transverse axis
- Inferior transverse axis
This axis is located posterior-inferior to the SI joint. It is involved in inominate/ilia rotation (anterior/posterior) during walking.
Inferior transverse axis
“Ilials around the inferior axis - I for an I”
True/False: Inominate motion around the ITA is anterior and posterior motion that occurs while walking, weight shifts, standing, sitting, and muscular forces of the lower extermities.
True
There are two oblique sacral axes:
- RIght oblique (Right base to Left ILA)
- Left bolique (left base to Right ILA)
This is a dynamic axis in which the sacrum engages during walking. For example, weight bearing on the left leg (by stepping forward with the right) will engage the _____ axis and cause the sacrum to turn towards the ______.
Left axis and turn to the Left
To recap, there are 4 different types of physiologic motion of the sacrum and inominates.
DRIP
- ________: sacram motion during walking around oblique axes.
- _____: sacram motion during breathing around the STA.
- _____: rotation around the ITA
- _____: sacral motion with bending forward and backward around the MTA
- Dynamic
- Respiratory
- Innominate
- Postural
Pubic symphysis is amphiarthrosis with strong ligaments and varying opposing surfaces. It is susceptible to hormonal changes and action of the adductor muscles.
True/False: Physiologic motion may occur about the transverse axes while walking.
True
*motion also occurs with one legged standing, childbirth
Pelvic Shear: Most often occurs superior/inferior. It results in
a. uneven tension on the pelvic/urogenital diaphragm
b. low back pain
c. anterior thigh pain
d. constipation, urinaty symptoms, dyspareunia, suprapubic pain
ALl of the above
What are the two important principles involves in physcial exam diagnosis of pelvic pain/dysfunction?
- Use at least 2 static landmarks
* find assymetry; ASIS heights) - Use a lateralizing test
* indicates side of dysfunction at SI joint
ex: AP compression test; Standing forward bending (Innominate/Pubic) and Seated Forward Bending (Sacrum)
Lateralizing tests indicate what side is more dysfunctional.
In the standing forward bending test (StFBT), a positive test usually indicates _______ dysfunction of the ______. It is sensitive to lower extremity restrictors (such as tight hamstrings)
Iliosacral dysfunction (innominate/pubes)
*PSIS moves greatest distance = dysfunctional
Lateralizing tests indicate which side is more dysfunctional. Seated forward bending tests is indicative of _____ dysfunction (i.e. sacrum). The lower extremity mechanics are eliminated.
Sacroiliac
**PSIS with most movement/greatest distance
What are the landmarks used to assess anterior pelvic dysfunction?
Iliac crest, ASIS, PSIS, pubic tubercles, medial malleoli (leg length)
Pelvis: The following findings describe what pelvic dysfunction?
- ASIS: superior
- PSIS: Superior
- Iliac crest: superior
- Pubic tubercle: superior
- Medial malleolus: superior
*abdominals, thoracolumbar fascia, pelvic floor
-Superior subluxation/Superior inominate shear
- Standing flexion test positive on that side
- non-physiologic dysfunction
NOTE: Symptoms: painful anywhere in pelvis, lower back or extremities
Pelvis: Describe treatment for a superior shear
- Hold above patient’s ankle
- abduct leg to 20 degrees; internally rotate hip
- apply traction and HVLA
- Recheck
Pelvis: The following findings describe what dysfunction?
- Inferior ASIS
- Inferior PSIS
- Inferior Iliac Crest
- Inferior medial malleolus
- Inferior pubic tubercle
Inferior inominate shear (down slipped ilia; minute inferior subluxation of inominate)
**rare, non-physiologic dysfunction
Patient tends to treat with ambulation
Symptoms: like superior shear
Pelvis: How do you treat inferior shear?
Patient hops up and down on dysfunctional leg; OR sits on dysfunction and bounces
Pelvis: The following findings describe what pelvic dysfunction?
- Superior PSIS
- Inferior ASIS
- Inferior Medial malleoli (longer leg)
- Everything Else is Level
* resists posterior rotation
Anterior Inominate ROtation
- inominate stuck in ant. on a transverse axis (ITA)
- tight rectus femoris
Pelvis: How do you treat anterior inominate rotation?
NOTE: always reset pelvis before performing
- Flex hip and knee to barrier (bend knee towards head)
- Stabilize sacral base
- Patient tries to extend hip/leg to resistance
* *repeat and recheck
NOTE: muscle energy is “joint mobilization”
Pelvis: The following findings describe what pelvic dysfunction?
- Inferior PSIS
- Superior ASIS
- Superior Medial malleoli (shortened leg)
- Everything Else is Level
* resists anterior rotation
Symptoms: groin or knee pain (meralgia)
Posterior inominate rotation
Pelvis: How do you treat posterior inominate rotation?
- Extend hip off table
- Stabilize other side (ASIS)
- Patient tries to bring leg up to resistance
- repeat w/ ME
- recheck at least 2 landmarks
Pelvis: The following findings describe what pelvic dysfunction?
External rotation around a vertical axis
- ASIS more laterally displaced from midline
- PSIS more medially displaced to midline
Outflare
Tx: 1. Flex hip to 90 degrees (medially) 2. Stabilize PSIS 3. ME (patient tries to abduct knee, with resistance) 4. Lateral traction to PSIS Repeat and Recheck
**Use lateral leg muscles (Abductors)
Pelvis: The following findings describe what pelvic disorder?
- ASIS more medially displaced
- PSIS more laterally displaced
- Internal rotation around a vertical axis
- Symptoms: Pelvic pain
Inflare
Tx: Indian style
- Abduct knee and stabilize opposite ASIS
- Patient tries to bring knee back to midline (adduct)
- Muscle energy; further abduct
- Repeat/Recheck
*Medial leg muscle to treat inflares
Pelvis: The following findings describe what pelvic dysfunction?
- Superior pubic symphysis
- Medial malleolus inferior (long leg)
- Everything else normal/symmetrical
Symptoms: suprapubic pain, constipation, urinary, LBP, anterior thigh pain, dysparunia
Superior pubic shear
Tx:
- Drop leg off table and stabilize opposite ASIS
- Patient adducts and Flexes leg (up and in)
- ME x 3
- Recheck
**adductors and abductors
Pelvis: The following findings describe what pelvic dysfunction?
- Inferior pubic symphysis
- Medial malleolus superior (short leg)
- Everything else normal/symmetrical
Symptoms: suprapubic pain, constipation, urinary, LBP, anterior thigh pain, dysparunia
Inferior pubic shear
Tx:
- Flex patient’s leg; stabilize ischial tuberosity
- Patient extends leg against resistance
- etc.
**adductor and abductors
Pelvis: What do I treat first?
LIPLSIP
- Lower extremity (majority of LBP)
- Innominate shears
- Pubic shears (somatic dysfunction)
- L5 (lumbars)
- Sacrum
- Innominate rotations (Ilia)
- Psoas (T12 and pelvis must be functional 1st)
*treat non-physiologic strains first
Sacrum: The Sacrum receives Sympathetic nerve supply via _______ and parasympathetic via ______
Sympathetic: T12-L4; sacral symp. trunk
PNS: S2-4 sacral plexus (left colon and pelvic viscera)
Sacrum: The Sciatic nerve is the muscular branch of the sacral plexus (L4-S3). It is closely associated with what muscle?
Piriformis
*piriformis hypertonicity can cause sciatica (referred pain to posterior thigh)
Sacrum: Which of the following are true ligaments?
a. Anterior sacroiliac
b. Interosseous sacroiliac
c. Posterior sacroiliac
d. Posterior iliosacral
Answer: A-C
Anterior sacroiliac:
–stretched w/ FLEXION; INCREASED lordosis
Posterior and Interosseous:
–stretched w/ EXTENSION; DECREASED lordosis
Sacrum: The accessory ligaments are Iliolumbar (L4-5 to iliac crest) and include:
- sacrospinous and sacrotuberous ligaments.
They restrain _____ movement of the sacrum
Anterior (Flexion)
Sacrum: _______ muscles including the erector spinae, and quadratus lumborum provide _____ to the sacrum.
stability
Sacrum: ________ influence sacral motion via attachment to the sacrotuberous and sacrospinous ligaments
Hip extensors
Sacrum: The iliopsoas is often involved in lumbopelvic dysfunction, while the _____ is the only muscle with direct attachment to the sacrum
Piriformis
Sacrum: The axes of rotation include
- Superior transverse (STA)
- Middle transverse (MTA)
- Inferior transverse (ITA)
- Left and Right Oblique (LOA and ROA)
This axis involves craniosacral flexion and extension and respiration
Superior Transverse axis
Sacrum: The axes of rotation include
- Superior transverse (STA)
- Middle transverse (MTA)
- Inferior transverse (ITA)
- Left and Right Oblique (LOA and ROA)
This axis involves lower extremity and innominate motion
ITA
Sacrum: The axes of rotation include
- Superior transverse (STA)
- Middle transverse (MTA)
- Inferior transverse (ITA)
- Left and Right Oblique (LOA and ROA)
This axis involves spinal (postural) flexion and extension
MTA
Sacrum: The axes of rotation include
- Superior transverse (STA)
- Middle transverse (MTA)
- Inferior transverse (ITA)
- Left and Right Oblique (LOA and ROA)
These axes involve walking and combined spinal motion
LOA and ROA
Sacrum:
- ________: anterior movement of the sacral base around a transverse axis in relation to the ilia
- _______: posterior movement of the sacral base around a transverse axis in relation to the ilia
- Flexion/Nutation
2. Extension/Counternutation
Sacrum: The following are motion tests for Sacral Diagnosis:
- L5 rotation
- Seated FLexion Test
- Backward bending (Sphinx)
- Lumbar spring
Describe what each tests for
- L5
- compensated; opposite sacral rotation - Seated flexion test
- -sacroilial motion (dysfunction)
- patient’s feet on the ground!! - BBT
- -ability of sacrum to flex w/ extension (BBT) of lumbar spine
- -negative: flexed
- -positive: extended - Lumbar spring
- -sacral extension prevents lumbar spring/flexibility
- -positive test: stiffness/lack of spring
- -negative: springy
Sacrum: Describe the steps involved in diagnosing the sacrum
- Positive seated flexion test (which one moves is dysfunction)
- -thumbs under PSIS - Deep Sacral Sulcus
- Which side is ILA posterior/caudad?
- Check L5. Is it compensated?
(Transverse process will be more posterior on the same side as the deep sacral sulcus – if sulcus is deep on right, transverse process posterior on the right) - Backward bending test
- -if it gets better (negative) = flexion (same letter)
- -if it gets worse (positive) = extension
Sacrum: In a flexed dysfunction, what soft tissue is involved? What are common symptoms?
Iliolumbar ligaments and anterior sacroiliac ligaments
*lower back pain, SI pain, pain with sitting, difficulty bending forward and difficulty getting up and down from a chair
Sacrum: The following findings describe what type of dysfunction?
- Seated forward bending test + on L.
- Left deep sacral sulcus
- Left post. caudad ILA
- L5 rotated Left
- BBT: findings improve/negative
(spring test -)
Left unilateral Flexion
*left side held flexed about the MTA
Sacrum: Describe how you would Treat a Unilateral Sacral Flexion
- Patient prone (on belly)
- Monitor sacral sulcus, abduct leg (15 degrees) and internal rotation slightly
- Place heel on hand on ypsilateral base of sacrum
- Apply anterior and cephalad force (during inhalation)
(resist with exhalation) - Recheck
Sacrum: The following findings describe what type of dysfunction?
- Positive seated flexion on R. side
- Deep sacral sulcus on Left
- Posterior caudad ILA on Left
- Positive BBT (gets worse)
- Positive lumbar spring
Symptoms: Lower back pain, difficulty bending backward, “lean over to pick up something and can’t get back up”
Right side Unilateral Extension
Sacrum: Describe how you would treat a Unilateral Sacral Extension
- Patient prone (on belly)
- Monitor sacral sulcus, abduct leg (15 degrees) and internal rotation slightly
- Place heel on hand on ypsilateral base of sacrum
- Apply anterior and caudad force (during exhalation)
(resist with inhalation)
x5
- Recheck
Sacrum: True/False: Symptoms of sacral torsions include: SI pain, LBP (lower back pain), sciatic and pelvic pain and bowel complaints.
They often involve the piriformis, tension on sacrotuberous and sacrospinous ligaments and tension on the pelvic floor muscles.
True
Named: Rotation/Axis
First letter: direction sacrum is rotated
Second letter: oblique axis
Sacrum: There are two forward (flexed) torsion: L/L and R/R
- WIth a L/L, L5 neutral mechanics should be rotated ____ but sidebent _____
Rotated Right (compensate) but sidebent Left
Sacrum: There are two backward torsions (L/R and R/L). With these torsions, L5 follows non-neutral mechanics. Thus,
- With a L/R torsion, L5 non-neutral mechanics should be rotated ______ but sidebent _____
- With a R/L torsion, L5 should be rotated _____ and sidebent _____
- rotated right, sidebent right
2. rotated left, sidebent left
Sacrum: Unilateral dysfunctions tend to have primarily flexion or extension dysfunctions on what sides?
- Flexed: MC LSF
- Extension: MC RSE
*bilaterals possible
Sacrum: Torsions involve anterior (flexed) or posterior (extended) dysfunctions that are most common on which sides?
- Anterior = L/L sacral torsion
2. Posterior = L/R sacral torsion
Sacrum: The following describes which type of sacral torsion?
- Positive seated flexion on Rt.
- Deep sacral sulcus on Rt.
- Posterior caudad ILA on Left
(axis on Left) - L5 compensated - rotated right, sidebent left
- BBT negative (gets better)
(spring test negative)
L/L sacral torsion
- Right side = flexed
- Left side = extended
- Rotated to the left (on LOA) – by right piriformis
NOTE: If it gets better = same letter, feet together, face the leather
Sacrum: Describe Tx for a Flexed (same letter) Sacral Torsion
Same letter, feet together, face the leather
- Patient on stomach
- bend knees up and push on PSIS to the side of dysfunction (same letter)
- Drop legs off table
- push on shoulder – ME (stabilize joint)
- ME w/ legs (stabilizing joint)
Sacrum - Extended torsions: The following findings are indicative of what type of extended sacral torsion?
- Positive seated flexion test on Left
- Deep sacral sulcus on Rt.
- Posterior caudad ILA on Left
- L5 compensated - rotated and sidebent Rt. (type II)
- BBT: positive (gets worse)
(spring test +)
L on R torsion
- left piriformis on ROA
- Left side: extension
- Right side: flexion
- Rotated: leftward
Sacrum: Describe treatment for Extended Sacral Torsions
- Patient lies on axis side
- Pull arm (lie them on back facing ceiling)
- push shoulder (ME)
- straighten bottom leg; drop top leg off table (ME)
Sacrum: The following describes what type of sacral dysfunction?
- Both sacrum are deep
- minimal motion with inhalation
- BBT and spring (negative)
- Seated flexion negative on both sides
Bilateral sacral flexion
Tx:
- Patient lies prone (belly)
- Abduct both legs
- Hand on bilateral ILA’s and apply anterior and cephalad force
* *inhalation
Sacral extension - inhalation
Sacral flexion - exhalation
Sacrum: The following describes what type of sacral dysfunction?
- Both sacrum are shallow
- minimal motion with exhalation
- BBT and spring (positive)
- Seated flexion negative on both sides
Bilateral sacral extension
Tx:
- Patient prone
- abduct legs
- heel of hand on base of sacrum and apply anterior and caudad force
* *exhalation
Sacrum:
- When the lumbars extend the sacral base moves ____
- When lumbars flex, the sacral base moves ____
- Flex: sacral base moves posterior (counter nutation)
2. Extend: sacral base moves anterior (nutation)
Sacrum:
- With inhalation, the sacrum moves _____
- With exhalation the sacrum moves _____
- Inhale: posterior
- –extension/counternutation - Exhale: anterior
- -flexion/nutation
Sacrum: When palpating the posterior surface of the ILA’s of the sacrum, the operator must sight _____ to the coronal plane of the _______ ILA
parallel, posterior
Sacrum: To assess sidebending (ILA caudadness), the operator must sight _____ to the transverse plane of the _____ ILA
tangent; inferior ILA
Sacrum: With sacral torsions, what are the involved tissues?
piriformis, sacrotuberous and sacrospinous ligaments, pelvic floor muscles
SIJD: True/False: The SI joint is a common source of LBP (lower back pain) in the general population because it is the link between the lower extremity and the spine.
It sustains higher loads for athletes and in pregnancy (most common etiology of LBP during pregnancy).
True
*neuro-myofascial-musculo-ligamentous injury”
SIJD: The fascia and muscles within the SIJD provide _____ or _____ to the SI joint and its ligaments through their cross-like anatomical configuration.
self bracing/self-locking
**NOTE: transverse abdominals important muscles (if weak = inc. SI pain)
SIJD: dorsal and ventral muscles associated with the SIJD include:
- transverse abdominals
- lat. dorsi
- glut. maximus
- ITB
- piriformis
- Iliopsoas
Of these, which is most important with regard to SI pain?
transverse abdominals
SIJD: True/False: Motion between the sacrum, spine and pelvis involves the gluteus maximus and latissimus dorsi which provide stability during the stance phase of gait, and provides mobility during the swing phase.
These form an “X” pattern on the dorsal aspect of the back (force closure)
True
SIJD: The SI joint is the only joint in the body that has a flat joint surface that lies parallel to the plane of maximal load.
It’s ability to provide stability and self lock occurs through 2 types of closure:
- Force closure
- Form closure
- Post. SI ligaments (added stability)
______ refers to how external compression forces add additional stability (e.g. post-gluteal/latissimus mechanism; ant- external and internal obliques, linea alba and transverse abdominals)
Force closure
SIJD: The SI joint is the only joint in the body that has a flat joint surface that lies parallel to the plane of maximal load.
It’s ability to provide stability and self lock occurs through 2 types of closure:
- Force closure
- Form closure
- Post. SI ligaments (added stability)
________ refers to how specifically shaped, closely fit contacts provide inherent stability independent of external load (e.g. shape of beveling joint surfaces)
Form closure
SIJD: Studies show a functional and anatomic connection between the _______ muscle and sacrotuberous ligament. The _______ is often short on the pathologic side of lower back pain.
Biceps femoris
SIJD: True/False: Hamstrings play an integral role in instrinsic stability of the SIJ
True
*Stretch hamstrings before treating lumbar spine
SIJD: Common tests for SIJ include
- Seated Flexion Test
- Patrick’s Test (FABRE)
- Gillet’s TEst (Stork)
- Gaenslen’s test
________ stresses the hip and sacroiliac joints. A positive test produces pain in the back, buttocks or groin
Patricks Test (FABRE)
SIJD: Common tests for SIJ include
- Seated Flexion Test
- Patrick’s Test (FABRE)
- Gillet’s TEst (Stork)
- Gaenslen’s test
If the SI joint is functional, then the PSIS will move down (on the side of the flexed leg) during this test. This means it is allowing the ilia to rotate.
Gillet (stork)
SIJD: Common tests for SIJ include
- Seated Flexion Test
- Patrick’s Test (FABRE)
- Gillet’s TEst (Stork)
- Gaenslen’s test
In this test, the hip joint is maximally flexed on one side and the opposite hip joint is extended. This maneuver stresses both SI joints simultaneously
Gaenslen Test
SIJD: There is no specific gold standard imaging test to diagnose SIJD.
Standard radiographs and bone scans may be used…however, the most sensitive test for ID of inflammatory sacroilitis is
MRI
Tx: analgesics, anti-inflamm, ice/heat, OMM, physical therapy, SI injection
Counterstrain: A dysfunction due to a continuing, inappropriate strain reflex which is inhibited by applying a position of mild strain in the direction exactly opposite to that of the reflex. This is accompanies by direct positioning about the point of tenderness.
Counterstrain (Spontaneous Release Positioning)
*Lawrence Jones
Counterstrain: After astute clinical observation followed by progressive expoloration, Dr. Jones made three discoveries. The three discoveries by Dr. Jones were as follows:
- Placing the body into a position of maximum ______ can treat somatic dysfunction.
- The _____ aspect of the patient must be evaluated, as well as the posterior, to effectively diagnose and treat somatic dysfunction.
- No matter how successful the treatment, if the return to neutral was not done _______ the benefit of treatment was lost.
- comfort
- anterior and posterior
- slowly
*correlation between symptoms, Hx and PE, structural findings and associated tender points are necessary for utilization of this approach
Counterstrain: Counterstrain utilizes tenderpoints, which are most commonly found in muscle tissue.
What type of technique is counterstrain?
Indirect
Counterstrain: There are 3 main theories of counterstrain mechanisms:
- Proprioceptive theory
- Sustained abnormal metabolism
(inc. circulation; dec. inflammation) - Impaired ligamentomuscular reflex
(strain on ligament inhibits muscle innapropriately)
With proprioceptive theory, one muscle is strained while the antagonist is _______. When the antagonist is suddenly stretched, receptors of the muscle spindles are subsequently stimulated resulting in reflex contraction of ALREADY shortened muscle.
Antagonist is hypershortened
- Indefinitely innapropriate
- proprioceptors in short muscle act as if muscle is being stretched
- Continuation of reflex = somatic dysfunction
Counterstrain: There is a relationship between the somatic dysfunction and the ID’d tenderpoints. Formation of these tenderpoints are believed to have occurred via
a. myotomal, dermotomal sclerotomal
b. motor points (where motor nerve crosses fascia and enters muscle to innervate)
Answer: A and B
Counterstrain: Trigger Point vs. Tenderpoint
The following describes which one?
a. patient presents w/ characteristic pain pattern
b. located in muscle tissue
c. locally tender
d. elicits jump sign when pressed
e. elicits a radiating pain pattern when pressed
Trigger point
NOTE:
Tender point = NO characteristic pain pattern, NO radiating pattern and Location (muscle, tendons, ligaments, fascia)
Counterstrain: List the steps for performing the Counterstrain technique
- Find the most significant/relevant tenderpoint
- Establish a tenderness scale
- Continuously ______ tender point for TART
- Place the patient ______ in a position that results in the greatest reduction of TART at the tender point
- Maintain this position for ____ with passive patient
- Slowly, passively, return to pre-treatment position while maintaining contact with the tenderpoint
- Re-evaluate
- Continuously monitor tender point
- Place patient passively in a position (comfort/ease)
- –slowly position
- -fine tune in multiple planes - 90 seconds
Counterstrain: What are you looking for in the various steps of Counterstrain technique?
- Find the most significant tenderpoint
- Establish tenderness scale
- Continously monitor tenderpoint
- Place in position of comfort
- Maintain for 90 sec
- SLOWLY return to pre-treatment position (patient must be relaxed)
- Retest the counterstrain tenderpoint (goal is <30)
- Find Tenderpoint
- -tenderness
- -small, tense, edematous
- -tenderpoint 4x more tender than adjacent tissue
* **NOTE: may be 180 degrees around the body from site of presenting pain - Scale
- 0-10
- -find 3 or below - Monitor
- Position of Ease
- -midline (flexion or extension)
- -lateral (sidebending/rotation)
* fine tune w/ small movement until reduce >70% - Maintain position for 90 sec
- -ribs may need 120 sec
- -therapeutic pulse (palpated)
- -check in
Counterstrain: True/False: For abbreviations, if lowercase, lesser movement in the direction should be used. If uppercase, greater movement (e.g. IR vs. ir internal rotation)
True
t-T = toward a-A = away SP: spinous process TP: transverse process CR: iliac crest OCC: occiput
Counterstrain: _____ intensity approximates radial pulse
therapeutic pulse
Counterstrain: _____ position at which at least 70% of tenderness is alleviated
position of comfort
Counterstrain: ___ position at which 100% tenderness is alleviated
Position of optimal comfort
Counterstrain: ______ situation which occurs in 20-30% of pateitns treated with counterstrain
therapeutic reaction
Counterstrain: ____: tenderpoint that does not respond to typical positioning. It require opposite position from the standard
Maverick
AC7: sidebend toward
PC3: flex
PC1 Inion: Flex
Countertrain: What are indications for counterstrain?
acute, subacute, chronic somatic dysfunctions of articular/myofascial origin
-adjunctive treatment of systemic complains w/ associated somatic dysfunction (e.g. viscerosomatic reflex causing rib dysfunction)
Counterstrain: What are absolute contraindications of counterstrain?
- abnormal neurological or vascular symptoms brought on by treatment position
- exacerbation of life threatening symptomatology by treatement position (e.g. EKG changes, drop in pulse ox)
Counterstrain: What are some relative contraindications?
- patient who cannot voluntarily relax
- severely ill
- upper cervical hyperrotation and hyperextension in pateitns w/ vertebral artery diesease, osteoporosis etc.
- inability to tolerate classic treatment position
- can’t effectively communicate
- severe acute rheymatological flare
- signs of apprehension
ex: Parkinson’s, vertebral artery disease
Counterstrain: What are the unusual treatments or very common treatments?
- piriformis
- -leg flexion to 120 degrees - cervicals
- -sidebend away, rotate away (SARA)
OMM Cardiovascular: Biomechanical considerations include
a. change in structure = change in function
b. altered structural components (bone, muscle, fascia) can impact CV function
c. adequate diaphragm, rib, and SK function
All of the above
–altered structural components: kyphoscoliosis (extreme); other postural alterations
–adequate diaphragm…(deconditioned state, previous surgery involving ribs, sternum; role in venous and lymph
OMM Cardiovascular: Biomechanical OMT
Once the patient is stabilized, soft tissue, muscle energy and articulation techniques may be used. The goal includes which of the following?
a. improve ROM and tissue texture
b. increase extremity movement to facilitate venous return
c. improve musculoskeletal relationships to assist the body in restoring homeostasis
Answer: ALL
OMM Cardiovascular: Respiratory/Circulatory considerations involve movement of fluids through the body, and focus on exchange of O2 and nutrients as well as waste removal.
Microscopically, the circulatory system removes waste such as ______ from anaerobic metabolism.
lactic acid
NOTE: must recognize importance of thoracic cage and diaphragm movement in low pressure systems (lymph, veins). **diaphragm = heart of lymphatic and venous system
OMM cardiovascular: Which of the following are approprate OMT treatments for improving the respiratory/circulatory systems?
a. Augment pharmacologic & respiratory treatments
b. Improve venous & lymphatic drainage; assist ability to reabsorb fluid that was third spaced
c. Articulation or ME to the thoracic outlet
d. Rib raising & soft tissue to improve compliance of thoracic cage
e. Gentle lymphatic pumps
f. Mobilize and ultimately remove excess fluid
Answer: All of the above
OMM Cardiovascular: The preferred homeostatic state of the Cardiovascular system is under parasympathetic dominance.
Increased sympathetic tone leads to:
- inc. heart rate and force of contraction
- vasoconstriction
- elevated b.p.
- inc. O2 demand (dec. cardiac flow)
Cardiac nociceptors travel with _____ and are very sensitive to ischemia and inflammation.
Cardiac nociecptors
NOTE: facilitation at the cord level leads to viscerosomatic reflexes
NOTE 2: esophagus and lungs share some of the same SNS innervation
OMM cardiovascular: Which of the following is NOT an effect of sympathetic influence on the cardiovascular system?
a. inc. catechols
b. inc. chronotropy/inotropy
c. inc. O2 demand
d. inc. coronary blood flow and diastole
e. cardiac remodeling
f. impaired lymph drainage
Answer: D
*dec. coronary flow and diastole
NOTE: cardiac remodeling - left atrium and ventricle
OMM cardiovascular: Parsympathetic (vagal) influence has opposite effects than sympathetic.
It reduces blood pressure, stabilizes the myocardium (anti-arrythmic) and increases coronary blood flow.
It involves what cervicals?
OA, C1, C2
OMM Cardiovascular: Which of the following are appropriate treatments for Neurological (sympathetic) issues with regard to CV system?
a. Viscerosmatic reflexes in upper T-spine
b. Treat upper cercicals
c. Identify SD contributing to patient’s patohlogy and de-facilitate VS reflexes to help restore autonomic homeostasis (parasympathetic dominance)
Answer: all of the above
A. Viscerosomatic reflexes (upper T-spine)
- -Tx w/ caution (avoid somatovisceral stimulus)
- -long term (dec. SNS)
B. Upper cervicals
–shift to parasymp. predominance
C. Somatic dysfunction causing patient’s pathology
–de-facilitate viscerosomatic reflexes
OMM Cardiovascular: Fatigue and Dyspnea are common in CHF patients.
They often follow the muscle hypothesis, which states:
- Muscles are less able to extract O2 from blood
- Intrinsic SK muscle changes
- Enhanced _______: increased ventilatory response to exercise
- Deconditioning and chronic muscle _____
- Enhanced ergoreceptors
- -exertional dyspnea - Chronic muscle hyperperfusion
OMM Cardiovascular: Which of the following is an appropriate treatment for improving metabolism/energy in CHF patients?
a. Exercise training and cardiac rehab
b. Pair w/ OMT for reduction of somatic dysfunction
c. Reduce work of breathing w/ better chest wall compliance (more efficient MSK function)
All of the above
A. Exercise training
- -efficient O2 use
- -dec. fatigue/dyspnea
- -reduce sympathetic tone
- -reduce neurohumoral activity
OMM Cardiovascular: Depression can be common in heart failure and CABG patients. It is often associated with increased mortality and re-hospitalization.
What are some things that should be considered in patients suffering from depression?
1.medication compliance
2. dietary compliance
3. allostatic load (Bruce McEwen)
(chronic exposure to neuroendocrine immune stress responses damages the body.
OMM Cardiovascular: Depression with CABG patients is common. It is divided into 3 categories:
- Class IIa
- Elderly
- Post-CABG depression (within 1 yr)
Explain with regard to treatment and prevention within these groups
- Class IIa
- -collaborative care can be beneficial - Elderly
- -lack of social participation/religious stregnth = predictors of death - Post-CABG
- -strongest predictor = depression before CABG
- -no significant inc. post
OMM Cardiovascular: Depression in Heart Failure patients is estimated at 63% due to worsened perception of health and worn outcomes.
What are multifactorial causes of depression?
a. ANS dysfunction
b. Inflammation
c. Cardiac arrhythmias
d. Altered platelet function
All of the above
OMM Cardiovascular: What are the benefits of OMT with regard to behavior/depression in CHF patients?
*NOTE: OMT should be combined w/ frequent outpatient visits, nursing services and counseling
–pre-menopausal women w/ dpression – improvement w/ OMT, psychotx + Paxil
–time w/ patient
*Decreases allostatic load
OMM Cardiovascular: Retrosternal pressure that starts with exertion or emotional stress and lasts longer than 10 minutes. It radiates to the arms, neck or jaw.
Symptoms include: nauesea, diaphoresis, fatigue, syncope
Ischemic chest pain
OMM Cardiovascular: Differentiate Primary vs. Secondary Musculoskeletal Pain with regard to the following categories:
- pain localized
- overuse/trauma/activity related to onset
- pain releived by rest
- pain worse at night
- unexplained weight loss
Primary:
- Localized: Yes
- Activity: Yes
- Rest: Yes
- Night: No
- Weight loss: No
Secondary:
- Localized: No
- Activity: Not usually
- Rest: Not usually (angina/claudication)
- Night: Yes
- Weight Loss: Yes
OMM Cardiovascular: Describe how to differentiate between primary and secondary musculoskeletal pain in a PE:
- passive joint motion restricted
- muscle point-tenderness to palpation
- pain reproduced by joint motion or muscle contraction
Primary:
–Yes to All
Secondary:
–NO to all
OMM Cardiovascular: Differentiate between primary and secondary musculoskeletal pain with regard to response to treatment
- amenable to manual treatment
- Further workup, diagnosis, treatment
Primary:
- -Yes (amenable; progressive)
- -No further workup (some chronic may)
Secondary:
- Not amenable (can be used secondarily)
- Further workup required
Do you use the standing or seated flexion test for sacral diagnosis?
Seated
Glossary: discriminates between forward and backward sacral torsion/rotation; discriminates between unilateral sacral flexion and extension
Backward bending test
Glossary: posterior movement of the sacral base around transverse axis
Counternutation
Glosary: posterior movement of the sacral base in relation to the ilia
Sacral extension
GLossary: anterior movement of the sacral base in relation to the ilia
6. Standing flexion test
Sacral flexion
Superior portion of innominate bone; (plural ilium)
Ilia
Glossary: 3 parts – ilium, ischium, pubis that meet at the acetabulum (head of femur sites). Also known as os coxae
Innominate
Glossary: motion of one innominate (ilium) w/ respect to the sacrum. Part of the pelvic motion during the gait cycle.
iliosacral motion
Glossary: A somatic dysfunction in whith the ASIS is anterior and inferior to the contralateral landmark. The innominate moves more freely in an anterior and inferior
Anterior inominate rotation
Glossary: A somatic dysfunction in which the ASIS is posterior and superior to the contralateral landmarks. The innominate moves more freely in a posterior and superior direction, and is restricted in an anterior and inferior direction.
Posterior inominate rotation
Glossary: somatic dysfunction in which the ASIS and PSIS are superior to the contralateral landmarks. The innominate moves more freely in a superior direction, but is restricted in an inferior direction.
Superior innominate shear
Glossary: Somatic dysfunction in which the ASIS and PSIS are inferior to the contralateral landmarks. The innominate moves more freely in an inferior direction, and is restricted from movement in a superior direction.
Inferior inominate shear
Glossary: somatic dysfunction of the innominate resulting in lateral positioning of the ASIS. The innominate moves more freely in a lateral direction, but is restricted with medial motion.
Outflared innominate
Glossary: somatic dysfunction resulting in medial positioning of the ASIS. The innominate moves more freely in a medial direction, and is restricted from movement in a lateral direction.
Inflared innominate
GLossary: nodding forward; anterior movement of the sacral base around a transverse axis (in relation to the ilia)
Nutatation
movement of the entire pelvis in a horizontal plane about a vertical (long.) axis
Pelvic rotation
Glossary: deviation of the pelvis to the right or left of the central vertical axis as translation occurs along the horizontal (z) axis. Usually observed standing.
Pelvic sideshift
Glossary: pelvic rotation about a transverse (horizontal) axis (forward or backward tilt) or about and anterior-posterior axis (right or left tilt)
Pelvic tilt
GLossary: right and left innominates + the sacrum + the coccyx
Pelvis
GLossary: osteopathic palpation, uppermost posterior portion of the sacrum. Most cephalad portion of the first sacral segment
Sacral base
Glossary: axis formed at the line of intersection of a sagittal and transverse plane.
Anterior-Posterior
GLossary: hypothetical functional axis of sacral motion that passes from side to side on a line through the inferior auricular surface of the sacrum and ilia. It represents the axis for movement of the ilia on the sacrum.
Inferior transverse (innominate)
Glossary: Hypothetical axis formed at the line of intersection of the midsagittal plane and a coronal plane.
Longitudinal
Glossary: Hypothetical functional axis of sacral nutation/counternutation in the standing position, passing horizontally through the anterior aspect of the sacrum at the level of the 2nd sacral segment.
Middle transverse (postural)
GLossary: hypothetical functional axis from the superior area of a sacroiliac articulation to the contralateral inferior sacroiliac articulation. It is designated as right or left relevant to its superior point of origin.
Oblique (diagonal)
Glossary: hypothetical transverse axis about which the sacrum moves during the respiratory cycle. It passes from side to side posterior to the attachment of the dura at the level of the 2nd sacral segment.
Superior transverse (respiratory)
Glossary: any of a group of somatic dysfunctions involving the sacrum. This may be due to normal physiologic motion or trauma to the sacrum.
Sacral somatic dysfunction
Glossary: depression just medial to the PSIS as a result of the spatial relationship of the PSIS to the dorsal aspect of the sacrum
Sacral sulcus
Glossary: physiologic function occurring in the sacrum during ambulation and forward bending. Occurs around an oblique axis in which a torque occurs between the sacrum and innominates. L5 should rotate opposite.
Sacral torsion
Glossary: motion of the sacrum in relationship to the innominates (ilium)
Sacroiliac
Glossary: The point on the lateral surface of the sacrum where it curves medially to the body of the 5th sacral vertebrae
Sacrum - ILA
Glossary: the initial general somatic examination to determine signs of SD in various regions of the body
Screen
GLossary: : an action or force causing/tending to cause two contiguous parts of an articulation to slide relative to each other in a direction parallel to their plane of contact.
Shear
GLossary: used to differentiate between backward or forward sacral torsions/rotations. Used to differentiate between bilateral sacral extension/bilateral sacral flexion. Etc.
Spring test
