systemic tx -- respiratory Flashcards
sinusitis
is inflammation of the sinuses that occurs with an infection from a virus, bacteria, or fungus.
sinusitis Causes, incidence, and risk factors
The sinuses are air-filled spaces in the skull (behind the forehead, nasal bones, cheeks, and eyes).
Healthy sinuses contain no bacteria or other germs. Usually, mucus is able to drain out and air is able
to circulate.
When the sinus openings become blocked or too much mucus builds up, bacteria and other germs
can grow more easily.
Sinusitis can occur from one of these conditions:
Small hairs (cilia) in the sinuses, which help move mucus out, do not work properly due to some medical conditions.
Colds and allergies may cause too much mucus to be made or block the opening of the sinuses.
A deviated nasal septum, nasal bone spur, or nasal polyps may block the opening of the sinuses.
which bones sinuses
frontal
maxillary
sphenoid
ethmoid
Acute Sinusitis Signs & Symptoms
..
severe pain usually b/c of
SEVERE PAIN USUALLY FROM INFECTION
ethmoid sinusitis (between/behind the eyes)
Nasal congestion with discharge or postnasal drip (mucous drips down the throat behind the nose)
Pain or pressure around the inner corner of the eye or down one side of the nose
Headache in the temple or surrounding the eye
Pain/pressure symptoms worse when coughing, straining, or lying on the back & better when head is upright
Fever is common
Pain/pressure symptoms worse when coughing, straining, or lying on the back & better when head is upright
(ethmoid sinusitis)
consider semifowler
Maxillary sinusitis (behind the cheek bones)
Pain across the cheekbone, around the eye, or around the upper teeth, pain/pressure on 1 side or both
Tender, red, or swollen cheekbone
Pain and pressure symptoms are worse with the head upright and bending forward & better when reclining
Nasal discharge or postnasal drip
Fever is common
Pain and pressure symptoms are worse with the head upright and bending forward & better when reclining
(maxillary)
also semifowler (?)
Frontal sinusitis (behind forehead, one or both sides)
Severe headaches in the forehead
Fever is common
Pain is worse when reclining and better with the head upright
Nasal discharge or postnasal drip
Pain is worse when reclining and better with the head upright
(frontal)
position?
Sphenoid sinusitis (behind the eyes)
Deep headache with pain behind and on top of the head, across the forehead, and behind the eye
Fever is common
Pain is worse when lying on the back or bending forward
Double vision or vision disturbances if pressure extends into the brain
Nasal discharge or postnasal drip
Pain is worse when lying on the back or bending forward
semifowler (?)
Chronic Sinusitis Signs & Symptoms
DULL ACHY, VAGUE SYMPTOMS
..
Ethmoid sinusitis (chronic)
Chronic nasal discharge, obstruction, and low-grade discomfort across the bridge of the nose
Pain is worse in the late morning or when wearing glasses
Chronic sore throat and bad breath
Maxillary sinusitis (chronic)
Discomfort or pressure below the eye
Chronic toothache
Pain possibly worse with colds, flu, or allergies
Increased discomfort throughout the day with increased cough at night
Frontal sinusitis (chronic)
Persistent, low-grade headache in the forehead
History of trauma or damage to the sinus area
Sphenoid sinusitis (chronic)
Low-grade general headache is common
RED FLAG / CI / PRECAUTION
Fever
Facial trauma
Intense, severe swelling affecting vision, hearing
Ongoing symptoms
Sinusitis Hx
Do you have a fever?
Does this affect vision, hearing?
Have you been dx by your doctor?
Do you have a history of sinusitis? How long?
Where do you feel the pain? How does it feel?
Have you had any dental work recently? Trauma to face?
Do you have any nasal discharge?
sinusitis observation
Swelling over sinuses/eyes/runny nose
Squinting eyes
Breathing through mouth
(sinusitis) PALPATION:
Gentle palpation over the frontal in the orbit of eye (superiorly) and maxillary sinuses under the zygomatic arch can be used to detect sinusits. There may be possible tenderness, heat and swelling.
(sinusitis) MOVEMENT:
Differentiate between tension HA and sinus HA –position change with increase sinus HA
DDX between other headaches, trigger points and facet
Decompression, compression
(sinusitis) NEUROLOGICAL:
Sympathetic innervation to sinuses in the upper t-spine pass through the c-spine ganglion.
(??)
(sinusitis) REFERRED PAIN:
There may be referred pain in the eyes, ears, neck, temples, teeth, cheeks back of head.
(sinusitis) SPECIAL TESTS:
Transillumination test
Palpation
SINUSITIS TREATMENT GOALS:
Relieve obstruction and pain
Effect reflex change
Improve mucociliary clearance
Treatment to all sinuses to assist drainage of all sinuses (although only one sinus may be infected.)
tx goals
- Reduce workload of breathing
- Ease removal of accumulated bronchial secretions and phlegm
- Improve lymphatic and venous flow
- Improve arterial circulation to carry immune system products to lungs
- Restore and maintain thoracic mobility
- Decrease hypertonicity of accessory muscles of respiration
- Reduce pain and discomfort by decreasing muscle spasm, TP’s and adhesions
- Identify and treat chronic hyperventilation
- Increase client’s awareness of “good breather”
- Other:
Postural Drainage Technique
Prior to performing postural drainage technique you need to:
- Rule out any CI’s to performing postural drainage (see below)
- identify which lobe(s) are/is affected with patient case history and special tests (vocal/tactile fremitus, percussion or auscultation)
- Teach patient to diaphragmatically breath and cough effectively
- Set up a signal for your patient to tell you to stop if they need a break
- Set up pillowing/table for the correct position, have garbage and tissues near by
Contraindications to Percussion:
Osteoporosis
Malignancy (and/or potential malignancy)
Inflammation in the area to be treated/percussed
Recent trauma in the area to be percussed
Pain during application of percussion
Demo and practice some mm of respiration in a semifowlers position
Diaphragm
Pec mj and mn (mj??)
scalenes
Demo and practice for sidelying treatment for respiratory conditions
Serratus anterior
Subclavius
Intercostals
Pectoralis mj and mn (mj??)
BRONCHIECTASIS
Progressive form of obstructive lung disease characterized by irreversible destruction and dilation of airways
Generally associated with chronic bacterial infections and cystic fibrosis
bronchiectasis risk factors / etiology
Any condition that produces a narrowed lumen of the bronchioles
E.g.
—> TB, viral infections, pneumonia, structural anomalies
Immunodeficiency
Genetic conditions
Cystic Fibrosis – Almost everyone with CF
BRONCHIECTASIS pathogenesis
All the causative conditions impair airway clearance mechanisms and host defenses, resulting in an inability to clear secretions and predisposing patients to chronic infection and inflammation.
Due to frequent infections, airways become filled with viscous mucous that contains inflammatory mediators and pathogens.
Airways slowly become dilated, scarred, and distorted.
Histologically, bronchial walls are thickened by edema, inflammation, and neovascularization.
Destruction of surrounding interstitium and alveoli causes fibrosis, emphysema, or both.
BRONCHIECTASIS – clinical manif
Persistent coughing with large amounts of purulent sputum
Dyspnea
Fatigue
Weight loss
Anemia
Fever
Hemoptysis
Weakness
Clubbing
Foul-smelling sputum
Diagnosis:
Imaging
History
Clinical manifestation
Genetic testing
Treatment:
Bronchodilators
Antibiotics
Corticosteroids
Hydration
Surgery
chronic bronchitis (COPD)
Chronic airflow limitation
Chronic bronchitis is defined as a productive cough lasting for at least 3 months per year for two consecutive years.
Etiology and Risk Factors
Exposure to environmental irritants
Age
Genetics
Smoking***
Specifically tobacco
Pathogenesis of Chronic Bronchitis:
Inflammation and scarring of bronchial lining leads to obstruction of airflow and increased mucous production
Irritants cause an increase in size and number of mucous producing glands and hypertrophy of smooth muscle cells
Leads to obstruction of airways
Impaired ciliary function predisposed to infection
Infection results in increased mucous production, bronchial inflammation and thickening
Clinical Manifestation of Chronic Bronchitis
Productive cough
SOB
Recurrent infection
Fever
Malaise
Cyanosis
Cor pulmonale
Barrel chest (uncommon)
Asthma (asthmatic bronchitis)
Characterized by conducting passageways that are extremely sensitive to irritation
Airways respond by constricting smooth muscles along bronchial tree, edema/swelling of mucosa, increased mucus
Breathing difficult; resistance markedly increased
Triggers include allergies, toxins, exercise
___
Increased responsiveness of bronchial tree to certain stimuli
Can be classified as reversible COPD
Chronic inflammatory condition with acute exacerbations
Complex disorder involving biochemical, autonomic, immunologic, infectious, endocrine and psychological factors
Risk Factors asthma
Environment
Small families
Lack of pets
Antibiotics
Age
Gender
Smoking while pregnant
Viral infections
Obesity
Urban settings
Low SE status
Overcrowding
BMI
Family history
Atopy
asthma etiology
Genetics
Viruses
Risk factors
Extrinsic Asthma (atopic or allergic asthma)
Results from an allergy to specific triggers
Occurs mostly in children and young adults
Hypersensitivity disorders
Intrinsic Asthma (nonallergic asthma)
No known triggers
Adult onset
Possibly viral exposure
—> Post-viral asthma
Occupational Asthma
Narrowing of the airways caused by workplace exposure
Exercise-Induced Asthma
Bronchoconstriction can occur in those without other forms of asthma
—> Up to 20% of the healthy population
More common in cold temperatures
pleurisy
“Pleurisy, also known as pleuritis, is inflammation of the membranes that surround the lungs and line the chest cavity (pleurae).”
pneumonia
“Pneumonia is an infection that inflames the air sacs in one or both lungs.”
“Pneumonia is inflammation and fluid in your lungs caused by a bacterial, viral or fungal infection.”
“Pneumonia is an infection that affects one or both lungs. It causes the air sacs, or alveoli, of the lungs to fill up with fluid or pus.”
Breathing Sequence
- diaphragm contracts
- lateral costal expansion as the ribs move up and out
- upper chest rises (accessory respiratory muscles should be at rest)
Indications for
Respiratory Assessment and Treatment
- COPD
- post-operation
- client who has been confined to bedrest
- abnormalities / decreased mobility of thorax
- postural disorders (extreme kyphosis, scoliosis)
- voice training, breath control (singers, actors)
- client who’s trying to quit smoking
- allergies
- chronic pain
- improved breathing awareness
- post traumatic stress disorder
- athletes
CAUTION: with advanced COPD,
the therapist must have MD’s referral to proceed with treatment
CI’s include
fever, sudden changes in patient’s condition
Considerations for treatment for a client
with advanced Respiratory Illness
History questions
CIs and precautions (Rattray & Ludwig P 881, 893 and 904)
Pre-treatment hydrotherapy
During treatment hydrotherapy
Post-treatment hydrotherapy
Negotiate long term and short term goals
Positioning for treatment, is there any modifications required? Bolsters? Slanted table? Other?
Is postural drainage appropriate? If so, perform the assessment to identify areas that need to be addressed.
Treatment techniques and modifications to treatment
-Durations: if client is fragile, shorter tx may be appropriate
-Tapotement/shaking/vibrations/rib springing etc appropriate?
-Breathing exercises/training
-Productive cough? As appropriate
Remedial exercise recommendations
(consider cardiac health)
Respiratory System – Assessment protocol
..
HISTORY
Diagnosis, when did they last see physician, have they been cleared for tx
Are they seeing other health practitioners (respiratory therapist, physiotherapist etc)
Medications
Episodes of dyspnea
Cardiac health history
Current physical exercise
ADLs
Cough, is it productive?
Triggers?
How long have they had the condition?
Xrays?
Areas of pain, soreness or discomfort?
Which lobe is affected?
Fever? Other symptoms?
OBSERVATION
Rate, rhythm, and effort of breathing
Colour – nail beds, lips (periphery, central)
Mouth or nose breathing
Jugular vein engorgement – associated with increased venous pressure and a sign of potential right ventricular heart failure
Shape of chest and the way it moves – location of breath
Musculature – tone
Posture – head forward? t/s kyphosis, rounded shoulders?
Shape and movement of nostrils
Shape of lips (smaller upper lip may indicate chronic hyperventilator)
Pursed lip breathing – may be COPD
Shape of face – longer lower third may indicate chronic hyperventilator
Compare one side to the other, work proximal to distal
Observation/inspection
Palpation
Percussion
Auscultation
PALPATION
Identify areas of tenderness, hypertonicity, atrophy – note them down
Palpate spine (feel for hyperlordosis/hyperkyphosis)
Assess abnormalities in ribs, spine etc
Elicit vocal or tactile fremitus
MOVEMENT
Assess rib excursion (if using measuring tape, note down measurements)
C/Spine and T/Spine
NEUROLOGICAL
Nerve entrapment TOS from overuse of accessory respiratory muscles
REFERRED PAIN
Trigger points from overuse of accessory respiratory muscles
SPECIAL TESTS
Rib excursion
Lobe expansion test
Percussion
Auscultation
Vocal/tactile fremitis
- RIB EXCURSION
Measure at the axilla, xiphoid process at the top of the inhale and at the end of the exhale with a tape measurement. Note that the measurements should be 3-7 cm apart for the inhale to exhale at each location.
- LOBE EXPANSION TEST
notes adapted from Therapeutic Exercise text – please refer to this text for a complete discussion of respiratory assessment
The purpose of this test is to assess the symmetry of the moving chest to consider the mobility of the thorax. It may indicate indirectly what areas of the lung may be or may not be responding.
Check upper lobe expansion
Stand facing your guest
Tips of thumbs at midsternal line, at sternal notch
Fingers above clavicles
Guest fully exhales, then inhales deeply
Check middle lobe expansion
Face your guest
Place tips of thumbs at xyphoid, extend fingers laterally around the ribs
Guest exhales fully, deep inhalation
Check lower lobe expansion
Go to the back of your guest
Place tips of your thumbs along their back, at the spinous processes (lower T/S); extend your fingers around their ribs
Guest exhales fully, deep inhalation
- PERCUSSION
Assesses lung density – i.e., air to solid ration in the lungs. Determines whether underlying tissues are air-filled, fluid-filled or solid. Only penetrates 5-7 cm – can’t detect deep-seated lesions
Place middle finger of non-dominant hand flat against chest wall along an intercostals space
Use tip of the middle finger of the dominant hand to tap firmly on the finger positioned along the intercostals space
Repeat at several points on right and left, anterior and posterior
Percussion produces resonance – pitch varies with density of underlying tissue
Abnormal (percussion test)
sound is dull/flat is there is too much solid matter (tumour, consolidation) in the lungs, compared to amount of air
sound is tympanic (hyper-resonant) is there is more air in the area (e.g. emphysema)
Normal (percussion test)
judgement is unique to the therapist; comes with percussing MANY chest walls
- AUSCULTATION
Listening to breath sounds -> indicate movement of air in the airways of the lungs during inspiration/expiration
Use a stethoscope:
Allows therapist to identify where congestion exists, so that postural drainage can be performed properly
Allows therapist to evaluate whether postural drainage has been properly/effectively performed
Guest sits in comfortable, relaxed position
Stethoscope is placed directly on guest’s skin, anterior and posterior chest wall
Follow a PATTERN along the right and left sides of the chest wall, anterior/posterior, so that you can accurately re-evaluate
Ask your guest to breathe in deeply and out quickly through the mouth as you move the stethoscope from point to point
Record your findings: note quality, intensity, and pitch
See text for detailed explanation of breath sounds
Deep breath through mouth – follow percussion path
Location, pitch and intensity ** note them down!
Normal vs abnormal and adventitious (extra): e.g. crackles, wheezes
- VOCAL/TACTILE FREMITUS
“The word “fremitus,” meaning a palpable vibration, originates from New Latin and Latin, derived from the verb “fremere” meaning “to roar, murmur” with the suffix “-tus” forming a noun of action.”
Place palms of your hands lightly on the chest wall
Ask the guest to speak a few words or repeat “99”
Normal: fremitus (vibration) is felt uniformly on the chest wall
Abnormal: fremitus increases in the presence of secretions in the airways; decreases/absent when air is trapped (obstructed airways
Goals of Breathing Exercises
Improve or redistribute ventilation
Increase the effectiveness of the cough mechanism and promote airway clearance
Prevent post-operative pulmonary complications
Improve the strength, endurance, and coordination of the muscles of ventilation
Maintain or improve chest and thoracic spine mobility
Correct inefficient or abnormal breathing patterns and decrease the work of breathing
Promote relaxation and relieve stress
Teach the client how to deal with episodes of dyspnea
Improve a client’s overall functional capacity for ADLs
Breathing Exercises
Clients should be in comfortable, relaxed positions with loose clothing on. (no tight bras, belts etc).
Advise the client to never force or prolong expiration – the breath should be relaxed and passive.
Work in cycles of 3-4 breaths at one time.
Try to bring awareness to natural breathing pattern:
1)abdominal
2)lateral costal
3)chest
Bring awareness to habit of initiating breathing with accessory muscles and upper chest (if they do so). I.e. during inspiration, upper chest should be “quiet”.
when is good for breathing exercise?
May be most effective to do breath training after a relaxing massage treatment.
Diaphragmatic Breathing
First the therapist uses their hand on the rectus abdominus, below the anterior costal margin, then the client does this.
Breath in through the nose, out through the mouth
Practice in different positions of their ADLs
Segmental Breathing
This is most effective when used to emphasize expansion of the problem areas of the lung and chest wall. E.g. because of pain and muscle guarding after surgery, collapsed lung, pneumonia, prolonged bed rest, etc.
(segmental breathing) Lateral Costal Expansion:
As the client breaths out, place a firm downward pressure into the ribs with the palms of your hands.
Just prior to inspiration, apply a quick downward and inward stretch to the chest.
This places a quick stretch on the external intercostals to facilitate their contraction.
These muscles move the ribs outward and upward during inspiration.
Posterior Basal Expansion
Repeat with hands over the posterior aspects of the lower ribs (especially important for bedridden post-surgical clients, who has to be in a semi-upright position for an extended period of time).
Right Middle Lobe or Lingula Expansion
Repeat with your hands just below the axilla (right or left)
Apical Expansion
Apply pressure, usually unilaterally, below the clavicle with the fingertips.
Pursed Lip Breathing
Creates a back pressure in the airways
Taught to clients with COPD to help deal with shortness of breath
Must not force the expiration
The client is taught not to contract abdomen – place your hands here to detect contraction
Instruct the client to breathe in slowly and deeply
Then have them loosely purse lips and exhale. (use the bending the flame analogy)
Shortness of Breath Attack During a Treatment
Have your client lean forward in a supported sitting position.
This stimulates diaphragmatic breathing – the viscera drops forward so the diaphragm can descend easier.
Teaching an Effective Cough
The client sits or leans forward with their neck slightly flexed
Therapist demonstrates: take a deep diaphragmatic breath and demonstrate 2 short coughs, contracting the abdomen
The client puts their hands on their abdomen and takes 3 “huffs” on expiration/exhalation, feeling his/her abdomen contract
The client practices making the “k” sound to experience tightening of the vocal cords and closing of the glottis
Ask the client to take a deep but relaxed inspiration/inhalation, followed by a double cough – the 2nd cough is more productive
NOTE: no gasping should occur
Manual Assisted Cough
..
Self-Assisted manual assisted cough
Sitting position: the client crosses arms over abdomen
After a deep breath in, push up and in on the abdomen, lean forward and try to cough
Therapist Assisted manual assisted cough
Therapist stands behind the seated client, with heel of one hand on the epigastric area of the client’s abdomen; the other hand is on top of the first
After a deep inhale, abdomen is compressed upward and inward
Treatment Goals for Respiratory Conditions
Reduce workload of breathing
Ease removal of accumulated bronchial secretions and phlegm
Improve lymphatic and venous flow
Improve arterial circulation to carry immune system products to lungs
Restore and maintain thoracic mobility
Decrease hypertonicity of accessory muscles of respiration
Reduce pain and discomfort by decreasing muscle spasm, TP’s and adhesions
Identify and treat chronic hyperventilation
Increase client’s awareness of “good breather”
Other:
Chronic Hyperventilation
Habitual breathing rate in excess of 18 breaths per minute
chronic hv ssx
Erratic heartbeats and/or chest pain
Breathless “attacks” at rest for no reason
Frequent sighing and/or yawning (average is once every 5-10 minutes)
Irritable coughing and chest tightness
Dizziness and “spaced out” feelings
“pins and needles” or numbness in lips, fingertips and toes
Gut disturbances – indigestion, nausea, wind or irritable bowel
Muscles aches, pains, or tremors
Tiredness, weakness, disturbed sleep, and nightmares
Phobias
Clammy hands, flushed face, feelings of high anxiety
Sexual problems
Normal, easy breathing
12 regular breaths/minute (10-14 acceptable)
70-80% of the work of respiration is done by the diaphragm
Accessory muscles of respiration are used during or shortly after extreme effort or stress
Inspiration: 2-3 seconds
Expiration: 3-4 seconds
Little or no upper chest movement
Nose breathing
This is reversed in chronic hyperventilators
Physiological changes related to Hyperventilation
Immediate:
Adrenalin pours into the bloodstream
Heart and breathing rates speed up
Muscles become tense
Eyesight and hearing sharpen
The pain threshold drops and pain is less intense
Chronic:
More carbon dioxide is breathed out; carbon dioxide levels in the blood start to drop
Normal pH becomes more alkaline = respiratory alkalosis
Smooth muscle cells are galvanized into action by lowered carbon dioxide levels, which leads to tightening or constriction of the blood vessels
The heart and pulses start pounding; the hyperventilator may feel panic stricken, with palpitations and chest pain
The brain may have its oxygen supply cut by as much as 50%
Habitual mouth breathers develop irritable upper airways, with the risk of repeated throat infections
A very common sign of hyperventilation is repeated throat clearing – the AAHHRRRRMMMMM bug
Triggers increased histamine levels in the blood – sweaty palms and armpits, clammy skin, flushed face are all signs of this
People with allergies such as hayfever, skin rashes, food intolerances, or asthma find their symptoms much worse
Response to pain is amplified – stiffness in muscles and joints feels rheumatoid-type pain
Heart disease-type symptoms, like tight chest pain or pounding pulses
Mental fuzziness, headaches, or loss of concentration can erode self-confidence, especially if work suffers
Making love can be a nightmare – for both partners – if the “heavy breathing” that precedes orgasm leads to a panic attack
Vivid dreams, nightmares, and disturbed sleep patterns commonly accompany hyperventilation – creates distress 24/7
Treating Hyperventilation
“BETTER”
Breath retraining
Esteem
Total body relaxation
Talk
Exercise
Rest and sleep
1) Becoming aware of faulty breathing problems
2) Learning to nose-diaphragm breathe
3) Suppressing upper-chest movement during normal breathing
4) Reducing breathing to a slow, even, rhythmic rate
LUNG HO Salute
Place your dominant hand on your abdomen, between the lower ribs and umbilicus
Other hand on the sternum; just below the clavicles
Take a deep breath
Notice which part of your chest moved first? Which part moved the most? Did you breathe through your nose or your mouth?
___
If you breathed in through your nose, your abdomen expanded first, and you felt almost no upper-chest movement, you are a good breather.
If you breathed in fast through your mouth, your upper chest heaved first, and you felt little or no movement, or your abdomen drew IN, you are a weak breather
Sinusitis Treatment
Adapted from “Sinus Drainage Techniques” by Eileen L. DiGiovanna
☺Frontal sinuses, milking, symmetrical, with thumbs
☺Frontal sinuses, draining/sweeping laterally toward the temples
☺Supraorbital notch; gentle pressure (analgesic effect)
☺Supraorbital notch/eyebrow ridge; sweeping bilaterally
☺Maxillary sinuses, milking, symmetrical, with thumbs
☺Maxillary sinuses, draining/sweeping caudad along each side of the nose to the corners of the mouth
☺Temporal areas: direct pressure; thenar eminences in the temporal fossae and gentle rhythmic bilateral pressure/release/pressure/release etc
☺Central structures: indirect pressure; interlaced fingers, palm up, under patient’s head, thenar eminences on lateral aspects of occiput; gentle rhythmic pressure/release etc.
☺Central structures: counterstrain technique; same hold, 90 seconds gentle pressure, then slow release (once only)
☺Central structures: one hand cups occiput, heel of other hand on patient’s forehead, gentle rhythmic compress/release/compress/release etc
☺Nasal decongestion: hands in “bird-like” formation, thumbs crossed on opposite sides of nose; alternate pressure, moving down length of nose; several times, then switch: same thumb, same side of nose, caudad sweeping down length of nose to corners of mouth, to drain
☺Maxillary sinuses: counterstrain technique; faced interlaced above nose, thenar eminences on lateral curve of zygomae; gentle medial pressure through the zygomae, compressing/lifting motion, anterior direction, hold 90 seconds
☺Maxillary sinuses: “fascial facial” technique (not included in DiGiovanna’s handout): suction-like “spidey-sensing” tips of all fingers/thumbs, gently grasp the zygomae and apply anterior suction-like pressure to “lift” the zygomae and create space at all articulating surfaces of the zygomae
☺Supraorbital tender points: one arm rests gently on forehead, gentle superior nudge; while other hand gently grasps/pinches bridge of nose and distracts it caudally
Appropriate supplementary techniques include manual lymph drainage, suboccipital release (cranial base decompression), and others at your discretion.
