OS Flashcards
Chapman’s point represents
The somatic manifestion of a visceral dysfxn
Appendix C.P.
Anterior- at the top of the R 12th rib
Posterior- at the TP of T11
Adrenal C.P.
A- 2” sup and 1” lateral to umbilicus
P- bt the SP and TP of T11 and T12
Kidney C.P.
A- 1” lat and 1” sup to umbilicus
P- Bt SP and TP of T12 and L1
Bladder C.P.
Periumbilical region
Colon C.P.
On the lateral thigh within the IT band from the greater trochanter to just above the knee
Cecum C.P.
A- at the R prox femur
Prox transverse colon at the hepatic flexure CP
Located at the R distal femur
Sigmoid colon CP
Located at the left prox femur
Distal transverse colon at the splenic flexure CP
Located at the left distal femur
Trigger point
Hypersensitive focus, usually within a taut band of sk m or in a muscle fascia. Painful on compression and can give rise to a characteristic referred pain, tenderness, and autonomic phenomena
Trigger point located in the R pectoralis m bt the 5th and 6th ribs intercostal space near the sterum
assoc SVTs
Trigger point represents the somatic manifestation of a viscero-somatic, somato-visceral or somato-somatic reflex
.
Txment for trigger points
Spray and stretch using vapocoolant spray
Injection with local anesthetics or dry needling
ME techniques
MFR
U/S, reciprocal inhib, or ischemic compression
Tenderpoint
Small, hypersensitive point in the myofasical tissue, treatment monitor for counterstrain. Taut myofascials bands that are painful on compression.
Tenderpoints DO NOT refer pain beyond the location compression
Trigger points may refer may when pressed
Tenderpoints do not refer pain when pressed
Goal of MFR
Improve lymphatic flow and restore functional balance
4 diaphragms all play a role in lymphatic return
Tentorium cerebelli
Thoracic inlet
Abdominal diaphragm - most important
Pelvic diaphragm
4 compensatory curves throughout the spine and their common compensatory pattern rotation (80% of healthy people)
- OA jxn -L
- Cervicothoracic jxn - R
- Thoracolumbar jxn -L
- Lumbosacral jxn -R
What empties into the R minor lymphatic duct?
R upper extremity, right hemicranium (head and face), heart and lobes of the lung (expect the L upper lobe)
What empties into the L main lymphatic duct?
The rest of the body
The thoracic duct traverses Sibson’s fascia of the thoracic inlet up to the level of C7 before turning and emptying into the left (major) duct
The R (minor) duct only traverses the thoracic inlet once
Structures the bypass lymphoid tissue and drain directly into the thoracic duct
Thyroid, esophagus and the coronary and triangular ligaments of the liver
Lymphatic system is primarily controlled by
Sympathetic system. Innervated by the intercostal nerves.
What level is the cisterna chyli? (Sympathetic control of lymph?)
T11
Factors the increase interstitial pressure above 0 mmHg that cause lymphatic ECF to enter lymphatic capillaries
Systemic HTN
Cirrhosis (decr plasma protein synthesis)
Hypoalbuminemia assoc with starvation
Toxins such as rattlesnake poisoning
CI’s to lymphatic txment
Osseous fractures, bacterial infxs with a temp > 102, absecess or localized infx, certain stages of carcinoma
Counterstrain
Passive indir technique in which the tissue being treated is postitioned at a point of balance, or ease, away from the restrictive barrier
Tenderpoint
Small tense edematous areas of tenderness about the size of a fingertip. Typically located near bony attachments of tendons, ligaments or in the belly of some muscles. DO NOT radiate pain
Maverick point
5% of tenderpoints will not improve with the expected txment wih careful fine tuning.
These Maverick points are treated by positioning the pt in a position opposite of what would be used typically
Anterior cervical tenderpoints
- usually slightly anterior to or on the most lateral aspect of the lateral masses
- tx: SB and R away from side of TP
Anterior cerical Maverick Points- Anterior 7th cervical
- about 2-3 cm lateral to the medial end of the clavicle at the lateral attachment of the SCM
- txment: flex, SB toward & R away from side of TP
Posterior cervical tenderpoints
- tip on the SP or on the lateral side of the SP
- txment: extend, SB, rotate away
Posterior cervical Maverick points- Inion (Posterior 1st cervical)
- at the inion (posterior occipital protuberance) or just below
- tx: marked flexion
Anterior thoracic tenderpoints
- T1-T6: midline of the sternum at the attachment of the corresponding rib
- T7-T12: located i nthe rectus abdominus m about 1” lateral to the midline on the R or L
- tx: flex thorax and add small amount of SB and R away
Posterior thoracic tenderpoints
- on either side of the SP or on the TP
- txment: Extend, R away and SB slightly away
Anterior Ribs tenderpoints
Anterior ribs assoc with depressed ribs (exhalation ribs, an exhalation dysfxn/inhalation restriction)
-hold 120 seconds
Rib 1: TP just below medial end of clavicle
Rib 2: TP is 6-8 cm lateral to sternum on rib 2
Txment Rib 1-2: Flex head, SB and R towards
Rib 3-6: TP along mid-axillary line on the corresponding rib
txment Ribs 3-6: SB and R the thorax toward, slight flexion
Posterior rib tenderpoints
- assoc with elevated ribs (inhalation ribs, inhalation dysfxn/exhalation restriction)
- hold for 120 seconds
- TP at the angle of the corresponding rib
- txment: most txed with minimal flexion, SB away and R away
Anterior lumbar tenderpoints
L1: Medial to ASIS
L2-L4: On the AIIS
L5: 1 cm lateral to the pubic symphysis on the superior ramus
Txment: pt supine, knees and hips flexed and markedly rotated away
Posterior lumbar tenderpoints
On either side of the SP or on the TP. L3 and L4 may be found on the iliac crest. L5 may be found on the PSIS
Txment: pt prone, extended and SB away (R may be towards or away)
Posterior Lumbar Maverick Point- Lower Pole 5th Lumbar
- Caudad to PSIS as much as 1 cm
- txment: pt prone, hip and knee flexed, leg IR and adducted
Pelvis Tenderpoints - iliacus
Approx 7 cm medial to ASIS
Tx: pt supine w/ the hip flexed and ER
Pelvis Maverick point - Piriformis
Usually in the piriformis m 7 cm medial to and slightly cephalad to the greater trochanter
Txment: pt prone, hip and knee flexed, thich abducted and ER
Facilitated Positional Release (FPR)
The component region of the body is placed into a neutral position, diminishing tissue and joint tension in all planes and an activating force (compression or torsion) is applied. Easily applied, non-traumatic, takes 3-4 secs to induce release
Used to tx: superficial mm, deep intervertebral muscles to influence vertebral motion
Muscle energy
Can be performed as an active direct or active indirect technique. Most txments are direct
ME: postisometric relaxation - direct technique
Physician takes pt into restrictive barrier. Pt provides activating force to ease of motion
- isometric contraction - where the distance bt the origin and the insertion of the muscle remains the same as the muscle conttacts will stretch the internal connective tissues
- golgi tendon organs senses this change in tension in the muscle tendons and causes a reflex relaxation of the agonist muscle fibers -> physician can then engage new restrictive barrier
ME: Reciprocal inhibition - direct or indirect
By contracting the antagonist muscle, signals are transmitted to the spinal ord and through the reciprocal inhib reflex arc, the agonist muscle is then forced to relax
Rib muscles
1: Anterior and middle scalenes
2: Posterior Scalene
3-5: Pectoralis Minor
6-9: Serratus Anterior
10-11: Latissimus dorsi
12: Quadratus lumborum
Pt postion for Forward Sacral torsion
Forward sacral torsion, pt lies Face down (axis side down)
-ex: L on L -> L lateral Sims position (lying on L side with face down)
Pt position for Backward sacral torsion
Backward sacral torsion = patient lies on their Back
Ex: R on L -> Left lateral recumbant with face up (axis side down)
Articulatory techniques ( springing techniques or low velocity/moderate amplitude)
Direct techniques that incr range of motion in a restricted joint
- physican engages the restrictive barrier and uses gentle repetitive forces to increase ROM within that joint
- respiratory cooperation and/or muscle energy activation can be added for my stretch of tight myofascial structures that may limit articular motion
- post-op and elderly pts find articulatory techniques more acceptable
Indications for articulatory technique
- limited or lose articular motion
- need to incr freq or amplitude of motion of a body region
- need to normalize sympathetic activity (rib raising technique)
Rib raising purpose - articulatory technique
Increase chest wall motion, normalize sympathetic tone, improve lymphatic return
-useful for pts who have a resistant or noncompliant chest wall, such as viral pneumo pt (pneumo= assoc with hypersympathetic activity)
Spencer’s techniques (7 stages) - used as articulatory technique
Useful in pt who have developed fibrosis and restriction during a period of inactivity (adhesive capsulitis) following an injury
-Ex: healed rotator cuff tear, immobilization of the shoulder girdle after a humerus fracture
Purpose of spencers technique
Improve motion in the glenohumeral joint. It is important that the physician limit motion at the scapula by placing his hand at the top of the pt’s shoulder
Stages of Spencer’s technique
1: stretching tissues and pumping fluids - arm extended
2: GH ex/flex with elbow flexed
3: GH flex/ex with elbow extended
4: a- circumduction with slight compression with elbow flex/ext
4: b- circumduction and traction with elbow extended
5: adduction and ER with elbow flexed
6: Abduction with IR with arm behind the back
7: stretching tissues and pumping fluids with arm extended
Hip-drop test
Assesses the SB (lateral flexion) ability of the lumbar spine and thoracolumbar jxn
- normal: lumbar spine SBs toward the side c/l to the bending knee, smooth convexity of lumbar spine on i/l side and i/l iliac crest should drop more than 20-25 degrees
- positive test = drop of iliac crest less than 20-25 degrees and anything less than a smooth convexity in the lumbar spine
Straight leg raising test (Lasegue’s test)
Test for sciatic nerve compression. Normal hip should be flexed to 70-80 degrees.
-pain = d/t hamstring tightness or sciatic n problems
Braggard’s test= lowers leg just below where pain was felt and dorsiflexes the foot to stretch the sciatic nerve. If no pain with this test -> tight hamstrings are the problem
Seated flexion test
Assesses sacroiliac motion -> evaluates SD in the sacrum and pelvis
Standing flexion test
Assesses iliosacral motion
-evaluates possibility of SD in the leg or pelvis, most commonly the innominate
Pelvic side shift test
Determines if the sacrum is in the midline
-it is often seen in a flexion contracture of the iliopsoas (psoas syndrome). A flexion contracture of the R iliopsoas will cause a + pelvic shift test to the left
Trendelenberg’s test
Assesses gluteus medius muscle strength. Pt picks up one leg off of the floor. Normally the glut medius should pull up the unsupported pelvis to keep it level. + test = pelvis falls -> weakness in the glut medius (superior gluteal n)
Lumbosacral spring test
Assess whether the sacral base is shifted posterior
+ test = little or no springing -> indicates sacral base moving posterior
Lumbosacral spring test will be positive in all dysfxns in which the sacral base moves posterior
+ test = u/l sacral extension, sacral margin posterior, sacral base posterior, and when sacrum rotates backward on an oblique axis
Backward bending test (Sphinx test)
Determines if the sacral base has moved posterior to anterior
+ test = part of the sacral base moves posterior
Normally, sphinx movement ( lumbar extension) causes the sacral base to move anterior
-physicians thumbs become more symmetric with lumbar extension, part of the sacral base moved anterior
-if the physicians thumbs become more asymm with lumbar extension, part of the sacral base has moved posterior
HVLA absolute contraindications
Osteoporosis Osteomyelitis ( including Pott's dz) Fractures in the area of thrust Bone metastasis Severe RA and Down's Syndrome -> weakness in the transverse ligament of the dens resulting in antlantal-axial subluxation
HVLA relative contraindications
Acute whiplash
Pregnancy
Post-surgical conditions
Herniated nucleus propulsus
Pts on anticoagulation therapy or hemophiliacs should be txed with caution to prevent bleeding
Vertebral artery ischemia (+ Wallenberg’s test)
Most common overall complication of HVLA
Vertebral artery injury. These problems arise with the use of cervical rotatory forces with the neck in the extended position
Most common HVLA complication in the low back
Cauda equina syndrome (very rare)
HVLA thoracics & ribs- Kirksville Krunch
Flexed lesion- corrective force directed at the dysfxnal segment and the thrust is aimed toward the floor
Extended lesion- corrective force is directed at the vertebrae below the dysfxnal segment and the thrust is aimed 45 degrees cephalad
Neutral lesion- txed the same way as a flexed dysfxn, but SB the pt away from you
Lumbar Roll Txment: Type 2 Dysfxn
If txing the pt with the PTP up -> pull pts inferior arm down
If txing the pt with the PTP down -> pull the pts inferior arm up
Lumbar Roll Txment: Type 1 Dysfxn
If txing pt with PTP up -> pull pts inferior arm up
Physiologic barrier
A point at which a patient can actively move any given joint
Anatomic barrier
A point at which a physician can passively move any give joint
-any movement beyond the anatomic barrier will cause ligament, tendon, or skeletal injury
Restrictive barrier (pathologic)
In SD, a joint will have a restrictive barrier. It lies before the physio barrier and prevents full ROM of that joint
Acute TART changes
Edematous, erythematous, boggy with increased moisture, muscles hypertonic, asymm present, restriction present, painful with movement. Severe, sharp tenderness.
Chronic TART changes
Decr or no edema, no erythema, cool dry skin, with slight tension. Decreased muscle tone, flaccid, ropy, fibrotic. Asymm present with compensation in other areas of the body. Restriction present with decreased or no pain. Dull, achy, burning tenderness
Cervical Facet Orientation
Backward, upward, medial (BUM)
Thoracic Facet orientation
Backward, upward, lateral (BUL)
Lumbar Facet orientation
Backward, medial (BM)
Flexion/extension motion
Plane = Sagittal Axis = Transverse
Rotation Motion
Plane = Transverse Axis = vertical
Sidebending motion
Plane = Coronal Axis= A-P axis
Isotonic contraction
Muscle contraction that results in the approximation of the muscle’s origin and insertion without a change in its tension
-operator’s force is less than the pt’s force
Isometric contraction
Musc contraction that results in the incr in tension without an approximation of origin and insertion
-operator’s force and pt’s force are equal
Counterstrain and FPR
Indirect and passive
ME and MFR
Only 2 that can be active txments
Foramen transvesarium of C1-C6
Foramina in the TP of C1-6 that allow for the passage of the vertebral artery
Scalene muscles
Originate from the posterior tubercle of the TPs of the cervical vertebrae and insert of rib 1 (anterior, middle) and rib 2 (posterior)
- SB neck with u/l contraction
- flex neck with b/l contraction
- aid in respiration
- tenderpoint = posterior to clavicle at the base of the neck with a 1st or 2nd inhalation rib dysfxn
SCM
Originates from the mastoid process and the lateral half of the superior nuchal line. Inserts onto the medial 1/3 of the clavical and sternum
- u/l contraction, SCM will SB i/l and rotate c/l (SB towards and rotate away)
- b/l contraction will flex the neck
- shortening or restrictions within the SCM can result in torticollis
RA and Down’s syndrome can cause weakening of what ligament
Transverse ligament of the atlas - attaches to the lateral masses of C1 to hold the dens in place
-can cause atlanto-axial subluxation
Joints of Luschka
In close proximity to the intervertebral foramina, degenerative changes and hypertrophy can lead to foraminal stenosis and nerve root compression
Nerve roots in the cervical spine exit above the corresponding vertebrae
.
OA
Motion of the occipital condyles on the atlas (C1)
- primary motion is flex/extension
- SB and R opposite sides with either F or E
AA
Considered to be C1 motion on C2
-primary motion = rotation
Ex: AA Rr = atlas (C1) is rotated R on the axis (C2)
C2-C7 motion
SB and R occur to the same side
- C2-C4- main motion = rotation
- C5-C7- main motion = SB
Cervical translation
Right translation = force from L to R = Left SB
Acute injury to the cervical spine txment
Best txed with indir fascial techniques or counterstrain first
MCC of cervical nerve root pressure sxs
Degenerative changes within the joints of Luschka and hypertrophy of the intervertebral (facet) joints -> cervical foraminal stenosis
Thoracic SP rule of 3’s
T1-T3, T12: SP located at the level of the corresponding TP
T4-6, T11: SP located 1/2 a segment below corresponding TP
T7-9, T10: SP located at the level of TP of the vertebrae below
Main motion of the thorax
Rotation
Diaphragm
Attachment: xyphoid process, ribs 6-12 on either side and bodies and intervertebral discs of L1-L3
Innervation: C3-5 = phrenic n
Typical rib landmarks
Tubercle: articulates with the corresponding TP
Head: articulates with the vertebra above the corresponding vertebra
Neck
Angle
Shaft
Typical ribs
Ribs 3-10
Atypical ribs
Ribs 1, 2, 11, 12
True ribs
Ribs 1-7 : attach to the sternum through costal cartilages
False ribs
Ribs 8-12: do not attach directly to the sternum
Floating ribs
Ribs 11 and 12: remain unattached anteriorly
Rib motion
Upper ribs (1-5) - primarily pump handle motion Middle ribs (6-10) - primarily bucket handle motion Lower ribs (11-12)- primarily caliper motion
Key ribs
Inhalation dysfxn key rib = low rib of the dysfxn
Exhalation dysfxn key rib = uppermost rib of the dysfxn
Erector spinae muscle group
Spinalis, iliocostalis, longissimus
Iliopsoas m = psoas major m and iliacus m
-maintaining lumbosacral angle
Origin: T12-L5 vertebral bodies
Insertion: lesser trochanter of femur
Action: primary hip flexor
SD: usually from prolonged shortening of the muscle
-pelvic side shift, + thomas test, SD of the upper lumbar segement
L4-L5 intervertebral disc is at the level of
Iliac crest
T10 dermatome at the umbilicus, which is anterior to
L3 and L4 intervertebral disc
Sacralization
One or both of the TPs of L5 are long and articulate with the sacrum. May lead to early disc degen
Lumbarization
Failure of fusion of S1 with the other sacral segments. Less common than sacralization
Main motion of lumbar
Flexion/extension
Motion of L5 influences the sacrum
SB of L5 cause a sacral oblique axis to be engaged on the same side
Rotation of L5 will cause sacrum to rotate to opposite side
Herniated nucleus pulposus
Most often between L4-5 and L5-S1
- herniated disc in the lumbar region will exert pressure on the nerve root of the vertebra below
- Ex: herniation between L3-4 = affect nerve root of L4
Psoas syndrome
- precipitated from prolonged positions that shorten the psoas
- pain in low back sometimes radiates to groin. Ache, muscle spasm
Psoas syndrome sxs/signs
- incr pain when standing/walking
- positive thomas test
- tender point medial to ASIS
- nonneutral dysfxn of L1 or L2
- positive pelvic shift test to c/l side
- sacral dysfxn on an oblique axis and c/l piriformis spasm
Psoas syndrome txment
Acute spasm may benefit from ice to decr pain and edema. Do not use heat initially. Do CS to anterior psoas then HVLA, ME to high lumbar spine.
-only stretch chronic psoas spasm
Example of key lesion for psoas syndrome
L1: F RrSr
L2-5: N RlSr
Spondylolisthesis
Anterior displacement of 1 vertebra in relation to the 1 below. Often occurs at L4 or L5. Usually d/t fatigue fractures in the pars interarticularis of the vertebra
Spondylolisthesis s/s
- incr pain w/ extension activities
- tight hamstrings b/l
- stiffed-legged, waddling type gait
- positive vertebral step-off sign
- goals of OMM: reduce lumbar lordosis and SD, HVLA is CI
Spondylolysis
-no anterior displacement
Defect usually of the pars interarticulars without anterior displacement of the vertebral body
-oblique views will identify the fracture of the pars interarticularis (collar of scotty dog)
Spondylosis
Degenerative changes within the intervertebral disc and ankylosing of adjacent vertebral bodies
-anterior lipping of the vertebral bodies
Cauda equina syndrome
Pressure on the nerve roots of the cauda equina usually d/t a massive central disc herniation
-saddle anesthesia, decr DTRs, decr rectal sphincter tone, loss of bowel and bladder control
dextroscoliosis
Curve that is SB L = scoliosis to the R
Levoscoliosis
Curve that is SB right = scoliosis to the L
Severity of Scoliosis
Mild- Cobb angle = 5-15
Moderate - Cobb angle = 20-45
Severe - Cobb angle = > 50
-resp fxn is compromised if the thoracic curvature is > 50
-CV fxn is compromised if the thoracic curvature is > 75
Short leg syndrome: anatomical or functional leg length discrepancy results in:
Sacral base unleveling
Vertebral SB and rotation
Innominate rotation
-MCC is hip replacement
Short leg syndrome s/s:
- sacral base unleveling: sacral base will be lower on the side of the short leg
- Anterior innominate rotation on side of short leg
- Posterior innominate rotation on side of long leg
- Lumbar spine will SB away and rotate toward the side of the short leg
- Lumbosacral (ferg’s) angle will incr 2-3 degrees
- First the iliolumbar ligaments, then the SI ligaments may become stressed on the side of the short leg
Short leg syndrome: get standing postural x-rays
If femoral head difference is > 5 mm, consider heel lift
Short leg syndrome: heel lift guidelines
- final lift height should be 1/2-3/4 of the measure leg length discrepancy unless there was a sudden cause of the discrepancy -> in that case lift the full amount
- the fragile (elderly, arthritic, osteoporotic, acute pain) pt- begin with a 1/16 (1.5 mm) heel life and increase 1/16” every 2 weeks
- flexible pt- begin with 1/8” (3.2 mm) lift and incr 1/8” eery 2 weeks
- max of 1/4” may be applied to the inside of the shoe
- max heel lift possible is 1/2” -> if need more need i/l anterior sole lift
Sacrospinous ligament
Originates at the sacrum and attaches to the ischial spines.
This ligament divides the greater and lesser sciatic foramen
Iliolumbar ligament
Originates from the TP of L4 and L5 and attaches to the medial side of the iliac crest. Often the first ligament to become painful in lumbosacral decompensation
Piriformis m
Origin: at the inferior aspect of the sacrum
Insertion: greater trochanter of the femur
Action: ER, extends thigh and abducts thigh with hip flexed.
Innervation: S1 & S2 nerve roots
-sciatic nerve can run through piriformis -> hypertonicity can cause butt pain that radiates down the thigh, but not usually below knee
Innominates rotate about what axis
Inferior transverse axis of the sacrum
-also the axis which an ant/post innominate rotation SD occurs
Sacral motion
Respiratory- motion occurs about the superior transverse axis of the sacrum at S2
Postural- motion occurs about the middle transverse axis of the sacrum
Sacral torsion rules
- When L5 is SB, a sacral oblique axis is engaged on the same side as SBing
- When L5 is rotated, the sacrum rotates the opposite way on an oblique axis
- The seated flexion test is found on the opposite side of the oblique axis
