quiqz flch card osteo.doc

8/10/2019 QUIQZ FLCH CARD OSTEO.doc

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ifferent from an allopathic diagnosis of the lower extremity?Motions=Gross vs. fineRelationships=Interrelatedness of subtle dysfunction on rest of functioning organism

Diagnosis & Treatment:Upper Half of the Body

Anterior RibsThoracolumbar JunctionCervicothoracic JunctionThoracics !ther Ribs"capulothoracic ArticulationCraniocervical Junction CraniumCervicalsRest of #pper $%tremity

Lower Half of the Body Diagnosis and Treatment Seqence&. 'ip restrictors (some of )hich cross the *umbo+sacral ,unction-. /ubic bone dysfunction0. "uperior innominate shear (1innom. upslip1-2. *umbar dysfunction (esp. *3 or4 less often *2-3. "acral dysfunction5. Innominate dysfunctions (other than upslip-

6. Iliopsoas (including thoraco+lumbar ,unction4 appro%. T&&+*-7. !ther *o)er $%tremity 8ysfunction

!ost "ommon SD9ibular head (antpost-Tibial rotation (inte%t-Talus (antpost-Calcaneal (inversioneversion-8ropped cuboidnavicularMetatarsal dysfunction


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"ommon #i$lar n%=:raps around posterior part of fibula="ensitive to trauma4 fracture or posterior fibular head dysfunction=In,ury at ;nee can produce )ea;ness of dorsifle%ors and foot drop (supplies(motor-

==anterior++deep fibular+== lateral


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= /regangionic fibers arise from T&&+*= "hared )ith innervation of pelvic organs via least splanchnic n. and lumbarsplanchnic n.= May e%plain Chapmans points along IT> for colon problems= *&+0 dermatomal pattern anterior thigh

Lymphatic Drainage' Sperficial=Abdominal )all belo) umbilicus=Gluteal region belo) iliac crest=/erineum (part of anal canal4 superficial &0 of penis4 vulva4 vagina-="uperficial part of thighs4 legs4 feet=8rainage into superficial nodes in inguinal and femoral triangle thendeep tonodes and channels arond femoral (ein in pper thigh

Lymphatic Drainage' Deep=/arallel path)ays along iliac veins to cysterna chyli= 8rains to thoracic duct (left lymphatic duct-= Receives drainage from left side of head and nec;4 posterior and upper lobe of leftlung.


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#nctional )natomy: *nee'')rticlar' femr and ti$ia+ motions andcompare

8ouble condylar comple% synovial ,oint formed by femoral condyles and tibialplateau

Medial and lateral semilunar cartilage (menisci- provide stability+ resistance topressure

Medial condyle longer than lateral. /rovides for=posterolateral glide )ith internal rotation=anteromedial glide )ith e%ternal rotation

femr and patella ,oint' patellar tendon cord le(el' and tendon atpatella=Gliding ,oint=Tendon of ?uadriceps femoris incorporates patella and attaches to tibial tuberosity/atellar tendon refle% at *2


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)rticlar' medial and lateral collateral ligaments*ateral"tabili@ation against lateral displacementot attached to lateral meniscus

Medial"tabili@ation against medial displacement

Attached to medial meniscusMa;es medial cartilage more susceptible to medial displacement or t)isting

#nctional )natomy: *nee'')rticlar crciate ligaments

Anterior attaches to anterior tibia/revents e%cessive anterior tibial glide/osterior to posterior tibia/revents e%cessive posterior tibial glide

Somatic dysfnction of -neeminor motionsB+anterior posterior glide+mediallateral glide+anteromedial or posterolateral glide (associated )ith inte%t rotation-


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.roximal Ti$iofi$lar /oint' ti$lar position% and motions of fi$la= "eparate synovial ,oint at the ;nee= !bli?ue angulation+ lateral anterior to medial posterior position=Motions at pro%imal and distal fibula are reciprocal=8orsifle%ion + foot+ moves distal fibula posteriorly4 pro%imal fibula glides anterior

=!pposite )ith plantar fle%ion (fibular head posterior-

)n-le'')rticlar' is there pre spination or pronation? ' also what isinclded in the an-le?+ 8istal tibia and talus

+ An;le mortice includes distal fibula (lateral malleolus-

+ Transverse a%is of an;le ,oint not parallel to transverse a%is of body4 foot isnormally in slight abductiono pure supination or pronation of the foot

an-le motions"upination $?uivalentInversion/lantar 9le%ion

Adduction

/ronation $?uivalent$version8orsifle%ion

Abduction


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Lateral )n-le Ligaments00

Anterior talofibular ligment/osterior talofibular ligamentCalcaneofibular ligament

ligaments disrpted in an-le in(ersion or 11111111111 sprainGrade I ++anterior talofibularGrade II +add calcaneofibularGrade III+ all lateral ligments torn

!otions of the foot' what does the -nee and ti$ia do?

Abduction$%ternal rotation of the tibia

Anteromedial glide at the ;nee

AdductionInternal rotation of the tibia/osteorlateral glide at the ;nee


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#nctional )natomy: #oot''!scles and Tendons ' !yofascial'posterior and medial maleols

Achilles tendon+ attaches to posterior calcaneus from common origin ofgastrocnemius and soleus mm.

/osterior to Medial Malleolus/osterior Tibial Tendon9le%or 8igitorum *ongus9le%or 'allicicus *ongus1Tom4 8ic;4 and 'arry1

#oot )nterior Tendons

Anterior Tendons

Anterior Tibialis Tendon+ "upports longitudinal arch$%tensor 8igitorum *ongus$%tensor 'allicus *ongus1Tom4 8ic;4 and 'arry1

Tendons .osterior to Lateral !alleols9ibularis >revis9ibularis *ongus+ "upports transverse arch


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Longitdinal )rches*ateralCalcaneus4 cuboid4 and metatarsals 2 and 3

MedialTalus4 navicular4 three cuneiforms4 metatarsals &+0

Trans(erse )rch' whats the msclar spport% what $ones ma-e pthis archCuboid4 navicular4 three cuneiforms4 and metatarsal bones

Muscular "upport++/eroneus (fibularis- longus inferiorly4 and tibialis anterior (firstcuneiform and first metatarsal


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D$$=*ateralMedial=Anterior/osterior=Anteromedial ($ET rot-/osterolateral (IT rot-

9ibular head motion

*ateral Malleolar Motion

"train to Interosseous Membrane

An;le Motion+Talotibial motion+"ubtalar motion+Intertarsal motion

#oot motionavicular bone dysfunction/lantar glide and medial rotation (inversion-

Cuboid bone dysfunction/lantar glide and lateral rotation (eversion-

Cuneiform dysfunction/lantar glide )ithout rotation

+Tarsal metatarsal ,oint motion=Generally less motion at the nd metatarsal=Minor motions are anteriorposterior glide4 mediallateral glide4 internale%ternalrotation glide


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Scan: Hindfoot and !idfoot"ubtalarInversion and $version at Talar Calcaneal

avicular/lantar position and tendernessMedial and inferior glideCuboid/lantar position and tenderness*ateral and inferior glide

Cuneiforms/lantar position/lantarinferior glide

MetatarsalsAdduction4 Abduction4 /lantar4 8orsifle%ion4 RotationMotion and /osition

#nctional )natomy: S$talar /ointTalocalcaneal Joint"econdary glide motions areInversion$version

Also Talonavicular glidesAnteromedial (eversion-/osterolateral (inversion-

L4 Scan Seqence00


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Dnee+Internal$%ternal Tibial torsion+9ibular 'ead

Midshaft

+Interosseous

An;le9oot+Talus+"ubtalar+Tarsal+Metatarsal

I 9 I T " T MI found in the stone4 the mallet

Diagnosis of 4xtremities: 5eneral S")'Comparison is made to opposite e%tremity

"can is guided byBChief complaint or"creening e%am findings in absence of complaint

"can chec;s for/osition andMotion

Diagnosis of 4xtremities: 5eneral' S")6amed in ease+Medial "ternoclavicular anterior and superior+/osterior 9ibular head

8ysfunction in secondary glides of ,oint (mainly-

Treatment 7ptions8irect9ind resistance position of ,oint

Move through that resistance by muscle energy4 springing4 or thrusting

Indirect9ind position of ease in all planes and phase of respirationRefine position as release occurs

Scan: *nee

/ositionB Tibial tuberosityMotionB Tibial rotation


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Scan: )n-le

/ositionB Talar domeMotionB Talar glide

#oot

4picondyles of the femr+/alpate the patella+"lide your thumb lateral to the outside of the ;nee+"lide bac; to the patella and move medially

Ti$ial t$erosity8 .atella how to do it? 9H?


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"it4 ;nee fle%ed+/lace hand on the anterior aspect of the ;nee (1;nee cap1-+Move fingers inferiorly until encountering a boney prominence

+#sed to determine mediallateral rotation of the tibia

+Continue do)n the tibia until reaching the medial malleolus

Ti$ial .latea+/lace thumbs on both sides of the patella+"lide inferiorly into soft4 ,oint space+Continue to palpate inferiorly until you feel bone

; )ngle*ess than &3 degrees in men

*ess than F degrees in )omen

+Increase in angle can result from e%cessive an;le pronation

+Increase in angle may result in patellofemoral syndrome


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Head of the fi$la' 9H4


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Calcaneo+fibular lig./osterior talo+fibular lig.

"alcanes where is it9ind the medial and lateral malleoli

8rop inferiorly onto the calcaneus (heel of foot-

a(iclar & "$oid 9H4


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"nieforms & !etatarsals+>egin palpation ,ust pro%imal to the metatarsal phalangeal ,oint.+$%plore all 3 metatarsal bones+The 3th metatarsal bone has a lateral prominencenamed the tuberosity of the 3th metatarsal+*ocate the &st metatarsal and move pro%imally to palpate a small ,oint bet)een themedial cuneiform and the &st metatarsal+Move onto the cuneiform and e%amine the bony structures more laterally (middleand lateral cuneiforms-

Screen8Scan for Somatic Dysfnction in the Lower 4xtremity+8irected at region of interest as identified by the patient (chief complaint-

+Assessed bilaterally for comparison of motion

+9ocus is usually on smaller secondary motions

+Attention must be given to ,oints above and belo) complaint area (at least-

+If dysfunction appreciated in neighboring regions must be further e%amined.

9hat is .ostral Balance?Continual adaptation of muscular tone in response to gravitational influences(among others-.


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D4#=46 7ptimal .ostral Balance/erfect distribution of body mass around the center of gravity4 )ith compressiveforces on spinal dis;s balanced by ligamentous tension.

!steopaths have agreed that the center of *0 is the center of average4 passive4standing adults. *i;e this guy.

9hy is .ostral Balance so =mportant?+/osture is but the formal e%pression of the balance of po)er e%isting bet)een theenvironmental force of gravity and the strength of the individual. Thus anydeterioration of posture indicates that the individual is losing ground in her contest

)ith the environmental forces of gravity.1


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+9asciaB sheets of fibroelastic connective tissue throughout the body

2 1crossover sites1 )here fascial tension can occur>ased on Junctiontransition areasCranium

Thora%/elvis

And the diaphragms that bridge them+Tentorium+Thoracic inlet+Abdominal diaphragm+/elvic diaphragm+Torsions of these fascial path)ays can compromise neural vascular flo).

$mbryologically4 transition @ones are )ea;er4 and more e%posed to acute orrepetitive trauma.

compensatory and noncompensatory mechanismsCommon compensatory patternB a series of myofascial torsions that are compatible

)ith physiologic function

on+compensatoryB not rotated in alternating directions+Compromises respiratory+circulatory integrity of body+Can be traumatically induced+:ill eventually display congestive systems

types of alignment' case considerationsI8$A*4 DH/'!TIC4 9*AT >ACD4 ":AH >ACDThe complaint of 1ec; /ain sho)s up in t)o different biomechanical environmentsin these t)o patients. (image & and -

:hich one is more li;ely to complain of tension headaches


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:hich one is more li;ely to be able to ta;e a deep breath &

:hich one might be more structurally vulnerable to case of pneumonia "tructure of the spine )ill affect the function of the thoracic viscera+ heart4 lungs.Can this person ta;e good deep breaths Can the heart efficiently provide enough

blood to the circulatory system.otential .ostral =nflencing History=Congenital>irth historyCongenital scoliosis (see appendi%-"houlder dystocia4 torticollis4 hip dysplasia

=Trauma"urgeriesIn,uriesChildbirthB vaginal4 c+sectionDneehip replacement/ostural imaging studies

=Medical 8iagnosisAsthma!steoporosispenia

=Activities!ccupationK")imming

:eight lifting

Diagnosis: .hysical 4xamLisual Inspection B loo; at your patients criticallyRememberB )ords have )eight thoughts are things

"tructural $%amB+gravity line+landmar;s

/alpatory $%am+screen and scan


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Landmar- re(iew+>ase of !cciput+"capular "pine+Inferior angle+Iliac crest4 /"I"

=="tanding fle%ion+Dnees+Arches of feet

gra(itational lineGravitational *ine "hould pass throughB&. $%ternal auditory meatus

. *ateral head of the humerus

0. Center of the >ody of *0

2. Anterior third of the sacral base

3. Greater trochanter

5. *ateral condyle of the ;nee

6. *ateral malleolus

A' >" T*M


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7) ,nction: $ase of occipt' case considerations= >iomechanicsB tonic nec; refle%es cranial strain patterns= euralB C e%it s;ull in this neighborhood= 9luidB vertebral artery to interior of cranium sagital sinus4 transverse sinus as

venous drainage= LisceraB C" sinuses= "8 at this level can induce+ 'ypertonicity of postural muscles+ 8isturbances of facial symmetry4 e?uilibrium and locomotor deficits.

CsB &F4&&4&

"T ,nction: scaplae case considerations= 1relatively mobile cervical spine meets relatively rigid thoracic spine.1=>iomechanicsB #$+shoulder girdle influences=="IT" muscles=="erratus anterior4 rhomboids4 pectoralis etc=euralB brachial ple%us4 phrenic4 vagus upper sympathetic chain=9luidB thoracic inlet=LisceraB headnec;4 heart4 lungs4 etc

TL ,nction: 2@Ath3 ri$s iliac crests case considerations

=8iaphragmK==>iomechanicsB s;eletal attachments==9luidB Aorta4 Lena Cava4 A@ygous fluid pump of body


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==LisceralB esophagus4 lo)er GI4 liver4 ;idney==euralB phrenic visceral sympparasymp considerations

=/ostural imbalance of *o)er >ody (biomechanics-==TonicB Iliopsoas4 *4 erector spinae

==/hasic or InhibitedB Rectus abdominus

Lm$o'sacral ,nction:='ori@ontal alignment of "acral >aseB==*!T" of implications into posture4 pain.=9luidsB inguinal nodes4 pelvic diaphragm=euralB lumbo+sacral ple%us4 pelvic and sacral splanchnics=LisceraB lo)er GI4 reproductive4 urinary considerations>iomechanicsB NNNNN NNNNN NNNNNN

!scle phys re(iew: alpha gamma motor neron re(iew= A disturbance of M" function initiates a series of events beginning )ithstimulation to mechanoreceptors and nociceptors4 resulting in afferent neural

activity...

= The final common path)ay is the alpha motor neuron that stimulates the musclefiber to contract4 and through the gamma system4 the muscle spindle to adapt4resulting in alteration in muscle tone. = Chronic dysfunction feeds the afferent loop4more nociception and abnormal mechanoreceptor information4 perpetuatingongoing aberrant muscle tone.8isturbanceResults in alteration4 adaptation

Interruption and reprogramming of the vicious cycle contribute to improvement ofoverall muscle tone and balance.


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:hat this means=J!> "$C#RITH

Short Leg SyndromeCondition in )hich there is an anatomical or functional leg length discrepancy thatresults in

&. "acral >ase unleveling. vertebral side bending A:AH and rotation T!:AR8" lo) side0. Innominate rotation and side shifting to)ards long leg2. and more

$arth is mostly even+ $yes level )ith the hori@onB pelvic imbalance can manifest

further a)ay (headaches- because of the bodys ability to compensate and adapt toimbalance

>et)een earth and eyes is )here the compensation and dysfunction can occur.

/elvis dropped to)ard the short leg"pine curves conve%ly a)ay from the short leg+ shoulders compensate opposite topelvis

"ommon #indings in Short Leg syndrome&. "acral >ase unleveling B lo)er on the side of the short leg.

. Anterior innominate rotation on the side of the short leg+ Iliacus contracture canbe source of this.0. /osterior innominate rotation on the side of the long leg.2. *umbar spine )ill sidebend a)ay and rotate to)ard the side of the short leg3. Iliolumbar ligaments may become stressed on the side of the short leg.5. "I ligaments may become stressed on the long leg side.

9hat happens when mscle pairs exert ne(en pll on fondation?how to fix?+Muscle ImbalanceB

+#pper Cross "yndrome+*o)er Cross "yndrome


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:AH" T! 9IE 9undamental /rinciples of Muscle Imbalances"ensory motor balance trainingB more here in year K"tretching of short4 tight (tonic- muscles 9IR"T."trengthening )ea;4 inhibited (phasic- muscles $ET.

Aerobic conditioning

!verall GoalsB=Maintenance of enhanced M" functional capacity=achieved by appropriate manual med intervention and a continual e%erciseprogram

Upper and Lower "ross Syndrome' C@ postral im$alance% Uppercross

/!"T#RA* IM>A*AC$+ /ostural muscles tend to)ards 'H/$Rtonicity+ dynamic muscles (phasic- tend to)ards 'H/!tonic overstretch.

Tonic = Tight = "hort = "trong/hasic = )ea; = *ong

+Asymmetry in tensions of agonist+antagonist pair+Imbalance can be in the coronalfrontal plane4 as in scoliosis... oranteriorposterior4 as in upper and lo)er cross.

#pper crossB anterior compartment tightens )hile the posterior torso )ea;ens .Lower cross follows similar general patterning+ /atterns4 not absolutes.+ /ostural imbalance of *o)er >ody (biomechanics-= TonicB Iliopsoas4 *4 erector spinae4 tensor fascia lata4 adductors4 piriformis4hamstrings.= /hasic or InhibitedB Rectus abdominus4 gluts (ma%4 med4 mini- obli?ues4 vastusmedialus4 lateralis4 tibialis anterior

+"tretching of short tight muscles

+"trengthening )ea; muscles+Aerobic conditioning


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Upper "ross =m$alance:#pper crossB anterior compartment tightens )hile the posterior torso )ea;ens .

Tonic

/ectoralis Ma,or/ectoralis Minor. * "capulae4 Tere Ma,or4 upper Trape@ius

Anterior 8eltoid"ubscapularis. *atissimus 8orsi4 Teres Ma,or"CM4 "calenes4 Rectus Capitus

/hasic


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Medically important in conte%t of resp+circulatory model>reath should move the torso from the nec;4 do)n to the pubic bone

*oo; forB motion from nec; to pubic boneAreas here that are Restricted to motion

C@: )nterior


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Stretches to Teach: pec minor8oor)ay "tretch +

:ith bac; straight4 align elbo) )ith eye against framestep for)ard )ith one foot.9eel the stretch in the /ectoralis area.&F+&3 seconds4 0+3%"hould pt stretch both sides

Upper half CA Thoracolm$ar /nction treatment8iaphragm redomingB

8iagnosisB using 9$4 ">4 R4 determine motions of ease.

TreatmentB Carry thora% to stac; these motions.'old in this position/atient can use breath to assist in 1un)inding1

>IG4 long4 easy breaths in and out4 or breath holding.

9ollo) diaphragm I4 )ith broad pressure4 on e%hale#ntil release is feltReturn to neutral and reassess.


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Diaphragm redoming: new/t supine4 doc seated/ass your hands around A/ diameter of thoracic cage.

Anterior hand at lo)er costal cage/osterior hand at thoracolumbar fasciaupper lumbars$ngage the tissue

Treat )ith direct or indirect methods4 stac;ing in 9$4 ">4 R.

lower half CA A3 .$ic $one dysfnction

Assess landmar;sB pubic tuberclesTreat asymmetric side

If no asymmetryB#se A>Adduction muscle energy+0 times in each direction

Upper half CE#pper picture sho)s combination of *evator and /ec'o) can this be modified to a M$ treatmentK


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Stretches to Teach: Le(ator Scaplae/atient seatedB/atient holds on to the side of the chair )ith one hand and fle%es the head as ifloo;ing and into the opposite breast poc;et.9ree hand is placed on the head and a gentle stretch is placed inferior and slightlylateral. 'old for 3+&3 seconds and repeat.

)ddress .hasic !scles%Inhibited muscles secondK#sually rhomboids4 midlo) trape@ius4 P+ serratus anterior4 latissimus.

CF in pper ' 7ccipital triangleCraniocervical ,unctions is last stop for postural asymmetry. $yes )ant to be level

)ith the hori@on4 semicircular canals demand a level environment to direct the headand body. /ostural asymmetry from the base up is 1corrected1 as a last effort at the

base of the s;ull to allo) the e%traoccular muscles the most level approach toenvironment as possible. These !cc triangle muscles have ?uite an intimaterelationship )ith the $!M4 and can perpetuate asymmetry if not corrected. "eeMyers Anatomy Trains4 "uperficial >ac; *ine for more information

=ndirect Tx for 7ccipital triangle+ /t supine.+ 9ind base of occiput )ith fingerpads+ Allo) pts head to sin; your fingers into the soft tissue.+ /ause here.

+ /atient ga@es softly to left neutral softly to right.#se e%traoccular muscles to stac; ease onto 9$4 ">4 R at occipital base.


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smmary @

smmary A

Spplemental 4xercises for Lower TrapeGis

/atient prone4 doc on side being testedAs; patient to activate *o)er Trap by pulling scapula inferiorly and mediallyto)ards the spineRetrainingB airplane armsK (to move activation lo)er4 can instruct pt to move into1)arrior I arms1


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Lower TrapeGis at home/roneB

or"tanding4 pull scapula together along spine (retraction->ring elbo)s fle%ed or e%tended along to)ards sides to appro%imately 23QRepeat 3+6 %(Also addresses rhomboids-

Serrats )nterior: inner(ation and fnction/ro% attachmentB Anterior surface of medial border of scapula8istal attachmentB ribs &+7InnervationB *ong thoracic nerveK

ActionB protracts and rotates scapula.+ A>8#CTI!

Spplemental 4xercises for Serrats"erratus Anterior +:ith patient laying on their side. The elbo) bent4 )hile fle%ing atthe shoulder."tretch for lo)er fibersB inferior angle moves medially and superiorly#pper fibersB move sup angle medially and inferiorly


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serrats strengthening"trengthenB Deep the arm parallel to the floor. May add resistance )hen the patientis able. (/rotracts "capula-"emi+truc; 'on; Motion.

Spplemental 4xercises for


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"ubtalar Inversion$version+Indirect

/lantar avicularCuboidCuneiform

+8irectIndirect

8orsal/lantarMedial*ateral Metatarsal+8irectIndirect

Dysfnction: *nee

Anterior tibial glide/osterior tibial glideMedial tibial glide*ateral tibial glide

Anteromedial tibial glide

/osterolateral tibial glideMost commonB anteromedial glide4 medial glide and posterior glide

Treatment: *nee8irect9ind resistance position of ,oint#se muscle energy or springing to activate

Indirect9ind position of ease in all planes

#se breath as activating forceDysfnction: )nterior #i$lar HeadTreatmentB 8irect Articular ("upine-9le% ;nee slightlyInternal rotation of tibiaThumb over fibular head4 opposite hand stabili@es lateral malleolusRapid e%tension of ;nee$ncourage posterior movement of fibula

TreatmentB 8irect Muscle $nergy

"eated positionThumb over fibular head directing posterior/lantar fle%ion of an;le to resistance (encourages inversion4 supination4 internaltibial rotation4 posterior pro%imal fibula-Isometric contraction dorsifle%ionRepeat

Dysfnction: .osterior #i$lar HeadTreatmentB 8irect Articular9le% ;nee

$%ternal rotation of tibiaMC/ or thumb posterior to fibular head


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9le% to resistance"pring fle%ion of ;nee to encourage fibular head anterior

TreatmentB 8irect Muscle $nergy"eated position

Thumb and finger grasp fibular head8orsifle%ion of an;le to resistance (encourages eversion4 pronation4 e%ternal tibialrotation4 anterior pro%imal fibula-Isometric contraction plantarfle%ionRepeat

Dysfnction: =nterosseos+/ro%imal or distal restriction identified by testing motion )hile palpating bothpro%imal fibular head and lateral malleolus

Treatment Indirect

+)hile holding pro%imal and distal fibula4 balance ease )ithin interosseusmembrane and soft tissue4 use breath as activating force

Dysfnction: )n-le+Anteriorposterior talusMost commonB anteriorplantar fle%ed talus

Treatment 8irect+"eated or supine++ dorsifle% foot until talus reaches edge of resistance4 have patientplantarfle% against resistance

Treatment Indirect"eated or supine plantarfle% foot to ease4 balance all motions possible4 use breath asactivating force

Dysfnction: S$tals motionInversioneversion of calcaneous

:ith associated posterolateralanteromedial talus

Treatment Indirect"eated or supine

"tabili@e talus4 find balanced ease in calcaneous4 use breath and reposition asspontaneous release

Dysfnction: a(iclar8"$oid8"neiform motion/lantar and medial rotation


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Treatment Indirect>alance ease in all planes4 use breath4 re+establish position in release

Dysfnction: !etatarsal motion8orsalplantar glide

Mediallateral glide

Treatment 8irect"eated or supine. "tabili@e metatarsal in ?uestion. Articulate MT through range ofmotion.

Treatment Indirect"eated or supine. >alance metatarsal into ease4 use breath to facilitate release4reposition accordingly

Upper 4xtremity:Screen"creeningBT)o Tissue Te%turesT)o Motion Tests

At each ,oint$valuate Joint /osition/alpate minor motion of ,oints

"pecific Joint )ill be compared bilaterallyoteB #nli;e the a%ial spine4 comparison of ,oints not above and belo)

Upper 4xtremity:)reas to Scan"houlder Comple% (2-"ternoclavicular4

Acromioclavicular4Glenohumeral4"capulothoracic

$lbo) Comple% (0-Radial 'ead4#lnar+'umeral JointInterosseous Membrane

:rist (0-Carpals4 Metacarpals4 /halanges


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Upper 4xtremity:Segmental Definition+8etermined during scan+Joint named for position of ease or motion of ease+9inding is relative to contralateral #$

$%. "ternoclavicular Joint"uperior Clavicle at "ternoclavicular Joint"uperior Glide at "ternoclavicular JointoteB "egmental definition in upper e%tremity is similar to segmental definition inthe a%ial spine

Sholder "omplexormal motion at shoulder involves motion at multiple ,oints"ternoclavicular

Acromioclavicular

"capulothoracicGlenohumeral

All 2 ,oints are assessed during upper e%tremity "can

Sternocla(iclar /oint ' position and motion/ositionB"uperiorInferior

Anterior/osterior

"uperiorInferior GlideAnterior/osterior GlideRotation

This is the only bony attachment of your arm to the bodyK $e;Important for proper shoulder motion!nly bony articulation to attach #$K

testing sternocla(iclar ,oint

To /alpate /ro%imal Clavicular /ositionB/hysician >ehind /atientThumbs on superior portion of pro%imal clavicle bilaterally


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Assess for superiorinferior position9ingers placed on anterior surface of clavicle bilaterally

Assess anteriorposterior positionoteB can be performed seated or supine

Sholder "omplex:

Sternocla(iclar /oint !otion To Test Sperior8=nferior 5lide:"hrug TestTo Test "uperiorInferior GlideB/alpate superior aspect of clavicle/atient 1shrugs1 shoulders4 then returns to neutralormal Motion/ro%imal clavicle glides inferior )ith shoulder shrug/ro%imal clavicle glides superior )ith return to neutral

!b,ectiveB Right Clavicle depressed at the "C ,oint )ith Inferior Glide

AssessmentB "omatic 8ysfunction of the #pper $%tremity

Sholder "omplex:Sternocla(iclar /oint !otion To Test )nterior8.osterior 5lide:To Test Anterior/osterior GlideB/alpate anterior aspect of clavicle/atient adducts and fle%es shoulder to FQ/atient reaches for)ard4 then returns to neutralormal MotionB

As patient reaches for)ard4 clavicle glides posterior

Return to neutral4 clavicle glides anterior


41/390

$%B!b,ective findingsB Right clavicle anterior at "C ,oint )ith Anterior Glide


Diagnosis


42/390

/alpate for 1stair+step1Compare bilaterally

motion testing for )" ,oint' To Test for )$dction (s )ddction:To Test for Abduction vs AdductionBMidde finger on distal clavicleInde% finger on acromion/assively abduct arm )hile palpating AC ,oint/alpate ,oint for restriction of motion and compare bilaterally

treatment of )" ,oint' addction ease treatment' !46

Muscle energy + Adduction ease/alpate AC ,oint/lace the pts AC ,oint into restriction4 abduction'ave patient contract against your forearm 0+3s/ost isometric rela%ationReposition ,oint into further restriction4 repeat 0+3 timesRechec;


43/390

motion testing for )" ,oint+To .alpate =nternal84xternal ring upper e%tremity to FQ=Grasp )rist and e%ternally rotate4 )hile palpating for restriction at AC ,oint

:rap arm under patients arm and grasp )rist4 internally rotate )hile palpating forrestriction at AC ,oint

$%ampleB

!b,ectiveB Right AC Joint positive stair+step4 abducted and e%ternally rotated


treatment of )" ,oint' internal rotation ease treatment' !46Muscle energy + Internally rotated AC+/lace the pts AC ,oint into restriction4 e%ternal rotation+'ave patient contract against your forearm 0+3s/ost isometric rela%ation+Reposition ,oint into further restriction4 repeat 0+3 timesRechec;


44/390

Scaplothoracic /oint' position and motion/osition/rotracted vs Retracted"uperior vs InferiorRotated #p)ard vs Rotated 8o)n)ard

MotionB"AM$

/alpate landmar;s and compare bilaterally

Sholder "omplex:Scaplothoracic /oint .osition Spine/lace palm of hand on each anterior aspect of each shoulder

Gently compress both shoulders and assess for resistance"ide of resistance = side of shoulder protraction


45/390

Sholder "omplex:Scaplothoracic /oint .rotraction: !sclar =n(ol(ement inprotraction:

Anterior $lementB /ectoralis Minor*ateral $lementB "erratus Anterior

Scaplothoracic /oint .rotraction' )ssess .ectoralis !inor )DT


46/390

Test motions for: Scaplothrocic /oint !otions"ame contact as for testing serratus

Test motions forB/rotraction vs retraction"uperior glide vs inferior glide#p)ard rotation vs do)n)ard rotation

$EB!b,ective 9indingsB 'ypertonic rhomboids )ith up)ardly rotated scapula


Diagnosis


47/390

5lenohmeral /oint .osition: and !otion/ositionB

Anterior vs /osterior

MotionBLoluntaryB9le%ion vs $%tension

Abduction vs AdductionInternal vs $%ternal Rotation

Involuntary MotionB "lideGlide )ith voluntary motion directions

Sholder "omplex:5lenohmeral /oint .osition/osition+/atient seated )ith physician behind+Thumb on acromion+Middle finger on anterior aspect of humeral head+Compare distance bet)een thumb and middle finger bilaterally

MotionThumb on acromionInde% and middle finger on anterior aspect of humeral head


48/390

"?uee@e thumb and fingers togetherCompare resistance to glide bilaterally

$%B!b,ective 9indingsB Right Anterior humeral head preferring anterior glide

AssessmentB "omatic 8ysfunction of #pper $%tremity

4l$ow "omplex: components'umeroradial Joint'umeroulnar JointInterosseous Membrane

Hmeroradial /oint .osition: and motion/ositionBRadial 'ead Anterior/osterior

MotionRadial 'ead Rotation on 'umerus

Anterior )ith "upination/osterior )ith /ronation

how to test position and motion

/!"ITI!&. Thumb anterior to pro%imal radial head


49/390

. Inde% and middle finger on posterior aspect of pro%imal radial head0. Compare >ilaterally

M!TI!Monitor at pro%imal radial head (as in previous slide-

:ith other hand4 grasp patients hand in the handsha;e positionMonitor pro%imal radial head )hile supinating and pronating the hand

$%ampleB

!b,ective 9indingsB /ro%imal Radial 'ead Anterior



50/390

Muscle $nergy + Anterior Radial 'ead/ronate the forearm to place radial head into restriction )hile palpating the radialhead'ave your patient supinate the forearm against your force/ost isometric contraction reposition and repeat 0+3 times

Rechec;

Muscle $nergy + /osterior Radial 'ead"upinate the forearm to place radial head into restriction )hile palpating the radialhead'ave your patient pronate the forearm against your force/ost isometric contraction reposition and repeat 0+3 timesRechec;

4l$ow "omplex:Hmerolnar /oint' position and motion' carrying angle/ositionB

Abduction vs Adduction

MotionBMa,or MotionB 9le%ion vs $%tensionMinor MotionB Abduction vs Adduction

Hmerolnar /oint .osition and motion


51/390

/!"ITI!Grasp $lbo) )ith both hands$valuate for increaseddecreased carrying angle and compare bilaterally

M!TI!

#sing both hands4 grasp the pro%imal ulna/lace patients )rist bet)een physicians elbo) and trun;

Add translatory force medially and laterally (adductionabduction-Compare >ilaterally

$%ampleB

!b,ective 9indingsB Right $lbo) increased carrying angle )ith right humeroulnar,oint abducted

AssessmentB "omatic 8ysfunction of #pper $%tremity

Diagnosis: .osterior radial head posterior translation radisincreased carrying angle"tabili@e the humerus + done by patient position.Ma;e contact )ith the pro%imal radius + cephalad hand caudad hand + hand sha;e.#se the motions available across the ,oint to enhance ease.

Antpost translation4 supinationpronation4 compressiontraction."tac;ing se?uentially #se respiratory ease $ventual "mooth Torsion Arc

=nterosses !em$rane


52/390

Important for supinationpronation at forearmActs li;e a shoc; absorber in trauma

To Test for Interosseous MembraneB/alpate for tension bands in forearm pro%imally ++Odistally

$%B !b,ective 9indingsB 9orearm Interosseous Membrane + Increased Tension 0distally


Diagnosis: #ascial restriction of interosseos mem$rane&. "tabili@e the humerus + done by patient position.. Ma;e contact )ith the pro%imal radius + pro%. hand distal hand + hand sha;e.0. #se the motions available across the ,oint to enhance ease.++"upinationpronation4 Medlat S Antpost translation4 fle%ione%tension4compressiontraction.2. "tac;ing se?uentially #se respiratory ease $ventual "mooth Torsion Arc

9rist:"arpal Bones and !etacarpals: .osition and !otion/ositionB

"uperior vs InferiorInternally vs $%ternally Rotated

MotionB$valuate for superior vs inferior glide$valuate for internal vs e%ternal rotation

$valuate each carpal bone and metacarpal and compare bilaterally

$%ampleB!b,ectiveB Right *unate Lentral



53/390

"arpal Bones and !etacarpals treatment"tabili@e the pro%imal bone )ith pro%imal hand.Ma;e contact )ith the distal bone )ith opposite hand#se the motions available across the ,oint to enhance ease.Medlat S Antpost translation4 fle%ione%tension4 compressiontraction.

"tac;ing se?uentially #se respiratory ease $ventual "mooth Torsion Arc

Diagnosis


54/390

Diagnosis


55/390

. Acromioclavicular 3. :rist0. Glenohumeral 5. 'and

"egmentally 8efinition>ased on motions at each uni?ue ,oint

ame in ease of position and motiongolfers el$ow% tennis el$owMedial epicondylitislateral epicondylitis

A types of cer(ical articlations"uperior (suboccipital- segment=C&(atlas- S C(a%is-=Integrated unit

=Connected to each other and the occiput=1Atypical1

Inferior segment (C+6-=Inferior surface of C(a%is- to superior surface of T&=Articulate at vertebral bodies )ith intervertebral disc=1Typical1

(erte$ral $ody shapesAtlas=o body4 ring shape

A%is=!dontoid process (dens-

C0+6="mall="addle "haped


56/390

Spinos .rocesses:Trans(erse .rocesses"pinous /rocessesB+>ifid+C&+none+C2+ shortest+C6+ longest4 nonbifid4 moves )ith fle%e%t+T& fi%ed

Transverse processes contain 9oramen Transversarium+Lertebral Lessels+Groove for spinal nerves

Trans(erse .rocesses:

Anterior Tubercles sharp

/osterior Tubercles bluntRidge palpated along lateral nec;


57/390

)rticlar pillars:+8eep in facial groove+>et)een semispinalis medially S cervical longissimus laterally"i@e of e%aminers finger pad"ame level as spinous process for C+C6

=nter(erte$ral dis-s=!A S AA==o discs==:eight+ !A ,oint+ a%is+ thru pedicles S laminae

=C0+6==:edge shape==Thic;er anterior==>odies articulate through intervertebral disc S small ==uncovertebral ,oints(*ush;a- laterally+not synovial


58/390

#inger width


59/390

#acet /oints "A'I+/lanes of facets not parallel++9ace bac;)ard and up)ard at 23 degree angle++Meet near tip of "/ of C6

+Angles of planes increase up)ard++&F+5F degrees+avg. incline of 23 degrees

"E'I Unco(erte$ral /oints+#ncinate process+ lateral ridge (lip- along superior surface of bodies of C0+6+/osterolateral corner vertebral bodies+9unction in gliding movements==9$+guide vertebral body motion==R and ">+*imit lateral translation+/rotect disc from posterolateral herniation+!steoarthritis

"E'I Unco(erte$ral /oints#ncinate process+ lateral ridge (lip- along superior surface of bodies of C0+6/osterolateral corner vertebral bodies9unction in gliding movements+9$+guide vertebral body motion

+R and ">+*imit lateral translation/rotect disc from posterolateral herniation


60/390

!steoarthritis

sideB !steoarthritis+lipping+ enchroaches on anterior aspect of lateral intervertebralcanal and affect spinal nerves

)tlanto')xial /oint''Three /oints!ne medial

Anterior arch of C&8ens of C

T)o *ateralInferior articular facets of C& +conve%

"uperior articular facets of C+conve%

)') !otion66 motions0+! J!IT+ & of cervical range of motion+Total rotation R!M+ 6F degrees+ 03 each side=='yperfle%ion loc;s out facets of C+6 S !A+ only AA rotates==Can get 23 degrees if other cervicals not fully loc;ed out

+"ome 9$+ &6 degrees

==9=for)ard S do)n $= bac;)ard S do)n=="mall amount side bending+involuntary )obble effect

==Anterior arch slides superiorinferior on dens==9acets al)ays engaged+o physiologic neutral


61/390

)) /oint00!dontoid process (dens-+Articulates on small synovial ,oint+ post. surface of ant. arch of atlas+ behind ant.tubercle+Transverse odontoid ligament #IV +/ost. surface + ;yphotic conve%ity+ allo)s ligament to slide+ permits for)ard

translation of atlasLigaments+Anterior longitudinal+ anterior body ++Olimits e%tension+/osterior longitudinal+ posterior body++Olimits fle%ion+*igamentum flavum+ posterior )all vertebral canalconnects laminae+*igamentum nuchae+ posterior nec;

Ligaments of )') ,oint fnctionCruciform *igament=prevent anterior displacement C& on C=Transverse+*ateral masses atlas over dens=*ongitudinal+8ens to ant. foramen magnum S a%is body

Apical *igament+Ape% dens to ant. 9oramen magnum

Alar *igament+Ape% dens to tubercle occipital condyle=$%tension+rela%ed

=9le%ion+taut


62/390

Jerte$ral )rtery=$nters C+spine bet)een T/ of C5+6=$%its superior to T/ of C&=Turns posterior over posterior arch of atlas C&=$nters foramen magnum=9orms >asilar Artery=>ony protection of Artery=$%tension can ;in; artery

+9oraminal passage for vertebral artery decreased by as much as 03W )hen cervicalcolumn is e%tended+Can narro) FW on contralateral side )ith rotation

+Combining hypere%tension )ith rotation can occlude the vertebral artery )here itpasses through the !A membrane

000"a(eat on o(erextension

Avoid overe%tension )hen palpating4 diagnosing and manipulating the cervicalspine

Caution + 8o)n "yndrome4 RA4 agenesis odontoid process4 fracture of odontoid

)tonomics E66Cervical Chain Ganglia="ympathetic control to the head and nec;

C+"mall branch connects to Lagus=Internal visceral disease

C0+3+/hrenic+ can treat hic+ups )ith this (inhibition P =pressure= 7FW hiccupsurvival rate lol-8iaphragm 8ysfunction


63/390

#lid*ymphatics=8eep Cervical odes=$%tensive lymphatic drainage in the cervical region

Lenous drainage=Jugular Lein9ascial constrictions influence drainage=Thoracic aperture

=Abdominal diaphragm

!o$iliGation with =mplse+Ma;e an accurate structural diagnosis+$ngage resistance in as many planes of motion as necessary for appropriatelocali@ation+The impulse force is vectoral.+8irection + into at least one restriction (9ryettes 0rd /rinciple-4+8uration S amplitude+ split second4 less than &7 + &2 inch of motion+/atient rela%ation is ;ey

+8eliver the vectoral impulse as the patient e%hales. This allo)s for a minimum offorce.+Rechec;

"ontraindications

Absolute=!steoporosis!steomyelitis9racture=Rheumatoid Arthritis8o)ns=:ea;ness transverse ligament

Relative

=Acute :hiplash=/regnancy=/ost !/='erniated 8is;=Anticoagulants=Lertebral Artery Ischemia

Rare occurrenceK=ec; strain=Cervical disc herniation=Lertebrobasilar accident

==="pontaneous occurrence has nearly t)ice the ris; )hen compared to cervicalmanipulation


64/390

=eurovascular accidents=Aggravation of disc problem=9ractures=Lertigo

B44#=TS6Is safe and effectiveIs comfortable and relieving for the patientIs simple and easy to doIs ?uic;Is taught safely )ith supervisionIs encouraged

Ac;no)ledged >enefitsBRelief of acute nec; painReduction subacute or chronic nec; pain

"hort+term relief of tension headacheRelief of cervicogenic headacheRelief of acute migraine symptoms

/otential 'armBLertebrobasilar accidentatural spontaneous occurrence rate nearly t)ice that associated )ith cervical'L*A

)(oiding "omplications

Avoid overe%tension

8iagnose accurately

8ont force beyond tolerance19eather+$dge1

Re+evaluate diagnosis and treatment method

Determinates of !otion' fryettes Erd9ryettes Third /rinciple

Initiation of motion of a vertebral segment in any plane of motion )ill modify themovement of that segment in other planes of motion

"A'I !otion0000 dysfnction9acet surfaces al)ays in contact unless traction appliedo physiologic neutral9acets al)ays engaged!nly non+neutral somatic dysfunction=Al)ays 1Type II li;e1=o group somatic dysfunction

"idebending and rotation to same side


65/390

W of the time no $#TRA* "$GM$T"+ Al)ays fle%ed or e%tended and 9R" (R and " in same direction-

"A'I !otionC+6 TerminologyTreating C5 is actually C5 motion on C6 for 'L*A

9le%ion+Inferior facets slide superioranterior on superior facets of vertebra belo)+Anterior translation of body+Intervertebral space compressed anterior+Gapping+tips of "/s

$%tension+Inferior facets slide inferiorposterior on superior facets belo)+/osterior translation of body+Intervertebral space compressed posterior

+Closing+tips of "/s


66/390

Lateral TranslationTest for "> mobility/assively move superior vertebraeTranslation = !pposite ">

Lateral Translation

Translate * and R+Monitor distance+ compare sides+Repeat in fle%ion and e%tension+Repeat at each cervical level

oth e%tremely useful"ome people prefer one over the other#sually combination of both

RotationB

/lace segment into R!TATI!A* restriction"idebendingB/lace segment into "I8$>$8IG restriction

"A'E HJL)'* articular pillars+"lightly sidebend segment to)ards $A"$+Rotate to R$"TRICTI!+9le% to segment

+"lightly e%tend at S above segment+uic; thrust thru both hands )ith rotational movement4 support hand does not


67/390

thrust+Rechec;

"A'I HJL)'Side Bending+/t supine on table )ith doc standing at head of table"upport head on side of ease )ith palm of hand (broad contact-+Contact articular pillar of segment on side of "> restriction )ith MC/ ,oint of inde%finger+"> to restriction over MC/ and translate to restriction+9le% or e%tend to segment+Rotate head to side of ease to loc; out segment above+Ad,ust 9$4 ">4 and rotation to locali@e+Translational thrust through articular pillar )ith inde% finger

+Rechec;

)lternate H)nd Hold for side'$endingAlternative 'and 'old+"upport head on side of ease )ith forearm+support chin in hand+8o !T thrust through chin. This is ,ust to add e%tra support

!ther TipsThrust should come from pectoral muscles (Robot ArmK-Remember 9ryettes /rinciplesK 8ont use more than 23 degrees of rotation


68/390

)')


69/390

+/atient supine+head at end of table+8oc stand at head of table+ feet apart4 ;nees bent4 elbo)s level )ith pt. head4 handsclose to body+"upport head )ith finger pads of both hands4 under center of gravity

+Translate head ;eeping it parallel to trun;+ move head by shifting body side to side

+$stimate amount of translation+=Translation = opposite side bending+Test in neutral and varied degrees of fle%ion and e%tension+8escribe findings in restriction then name diagnosis by position (ease-.

!+A *ateral Translation TestB Translation Resistance *eft or Right )ith the 'ead in9le%ion or $%tension =O 8iagnosis (9"leftRright4 $"leftRright4 etc.-

$%ampleB $"RR* ($"Rleft-

"er(ical Stretching*inear Traction"tretch+*o)er cervical muscles+/osterior cervical muscles

/erpendicular "tretch

>ilateral "tretch

7): #lexed side $ent right rotated leftTreatmentB

*eft 'and contacts left occiput at A! articulationRight 'and cradles the head and nec;.GoalB Carry the left occiput for)ard on the atlas + to)ard the opposite orbit/atient Rela%ationBTa;e a deep breath in4 then let it out slo)ly.*et your head drop to)ard the table.

8%B 9"rRl


70/390

7): #lexed side $ent right rotated leftGoalB Carry the left occiput for)ard on the atlas

9orce must be directedB+"uperior to disengage the facet ,oint+Medial S Anterior to follo) the plane of the facets

The Resulting Lector is To)ard the !pposite !rbit

8%B 9"rRl

7): 4xtended side $ent right rotated left*eft 'and contacts left occiput at the A! articulationRight 'and cradles the head and nec;.GoalB Carry the right occiput bac;)ard on the atlas + to)ard the opposite orbit

+"idebend *eft Rotate Right into resistance/atient Rela%ationB=Ta;e a deep breath in4 then let it out slo)ly.=*et your head drop to)ard the table.

8%B $"rRl

7): 4xtended side $ent right rotated leftGoalB Carry the right occiput bac;)ard on the atlas (stuc; facet-

9orce must be directedB+"uperior to disengage the facet ,oint+Medial S Anterior to follo) the plane of the facets


71/390

+To)ard the !pposite !rbit

otice the "ubtle Change in Lector S *ocali@ation to)ard the right facet ,oint

8%B $"rRl

.ractice HJL)' cer(ical thoracic lm$arImportant points+&. motion of C is primarily rotation+'L*A here is rotation into resistance. cervicals C+6 behave 9ryette li;e+ Type mechanics+ rotation and side bendingopposite directions (! :R!G "AM$-0. correct upper e%tremity position for thoracic 'L*A2. 9le%ed and e%tended thrust direction3. /ractice K Contact your friendly local !MM fello) for assistance

"ool Down: .ost'Treatment"oft Tissue*inear Traction"tretch*o)er cervical muscles/osterior cervical muscles/erpendicular "tretch>ilateral "tretch!R!ther treatment modalities9unctional Methods9/R

Muscle $nergy"ontraindications h(laMobili@ation )ith Impulse

Absolute!steoporosis!steomyelitis9ractureRheumatoid Arthritis8o)ns

:ea;ness transverse ligament8o)n syndrome4 RA4 agenesis odontoid process4 f% odontoid4

RelativeAcute :hiplash/regnancy/ost !/'erniated ucleus /ropulsus

AnticoagulantsLertebral Artery Ischemiacongenital asymmetry4 atresia

)tonomics

"uperior cervical ganglion"ympathetic control cervical blood flo)


72/390

>ound by deep connective fasciaReceives preganglionic fibers of T&+2

Lagus/arasympathetic innervation to most internal organs

Jugular foramenB e%it of C 4 &F4 and &&Lymphatics+$%tensive lymphatic drainage in the cervical region + 8eep Cervical odes inrelationship to !A S AA9ascial constrictions influence drainageThoracic aperture

Abdominal diaphragm

Spinal Dra !ater ' )ttached to:Circumference of 9oramen Magnum/osterior "urfaces of the >odies ofBCC0

7) /ointCranium sits on atlas li;e a sphere

Main motion is 9le%ion$%tention&3 degrees

"idebending and rotation to opposite sides*ateral atlanto+occipital ligament

7) !otion Testingodding test+/t. moves head into 9$


73/390

+!bserve for lateral deviation of chin

/atient supine (Active Motion Test-+8oc standing at head of table+/atient nods head )ithout lifting it off table

+9le%+ tuc; chin+ condyles slide bac;+$%t+ bac;)ard nod+chin anterior+ condyles slide for)ard+!bserve for lateral deviation of chin in fle%ion or e%tension

*ateral translation+8oc at head of table4 hands on patients head4 elbo)s level )ith patients head+Translate head by shifting body side to side==Remember sidebending and translation are opposite+Test in neutral and )ith small degrees of 9$

Determining the KStc-K #acet

As the occiput fle%es4 the condyles move posteriorly

As the occiput e%tends4 the condyles move anteriorly

/refers fle%ion+resists e%tension+condyle cannot move bac;+occiput rotates a)ay from stuc; facet

/refers e%tension+resists fle%ion+condyle cannot move for)ard+occiput rotates to)ard stuc; facet

#ascia+/revertebral fascia contacts the cranial base+Investing layer of cervical fascia is continuous )ith periosteum of hyoid S sternum+/retracheal fascia fuses )ith fibrous pericardium


74/390

7) ,oint

H$" Joint+ !AB "idebending S Rotation occur to opposite sides

+9le%ion$%tension+ Transverse a%is+/rinciple motion+&3 degrees motion bet)een e%treme fle% and e%treme e%t+ AA contributesadditional &6 degrees+"ide >ending+ A/ a%is+*imited to 5 degrees side to side+Rotation+Lertical a%is+/ure rotation nearly impossible+"idebending S Rotation are Coupled Motions

motions 7) ,oint!A e%tension re?uires that the occipital condyles move anterior on the atlas.

!A fle%ion re?uires that the occipital condyles move posterior on the atlas.

7') Spine odding Test0Chin deviated to & side+!cciput rotated to that side+"idebent to opposite side

#nilateral fle%ion+Rotation to same side+"idebent opposite

#nilateral e%tension+Rotation opposite+"idebent to same side


75/390

7) )lternati(e TestsIntersegmental Motion testing'ands supporting occiput )ith inde% fingers in occipital sulcus lateral to midline.Motion is induced )hile fingers are monitoring response.

!ne hand supporting occiput )ith inde% finger and thumb of other hand stabili@ingand monitoring motion at occipital sulcus lateral to midline. Monitor response

)hile motion testing

"ide of shallo) sulcus is the side of sidebending preference

9le%ed or $%tended positionB :hichever the sulci are most even is the direction of

ease7) =ncremental !o$iliGation =+#se the cephalad hand to gently cup the occiput+#se the thumb and inde% (or middle finger- to contact the lateral masses of C& Addfle%ion or e%tension according to your diagnosis.+Cephalad 'andB add cephalad traction do)n into the !A facet articulations (todisengage the facets-+Caudad 'andB introduce rhythmic translatory motion against the resistancepreviously diagnosed=Lisuali@e the angle of the facets at that level

=Lisuali@e the vector of force going to the restricted facet7) =ncremental !o$iliGation =="ame 'and Contact for >oth 'ands

Cephalad 'andB add cephalad traction do)n into the !A facet articulations (todisengage the facets-Caudad 'andB holds the atlas motionless=Lisuali@e the angle of the facets at that level

Cephalad 'andB Add Translatory Motion rhythmically do)n to the restricted facet=Lisuali@e the vector of force going to the restricted facet


76/390

which condyle is stc-? #L4=7rotation is to the side of the freely moving condyle

which condyle stc- 4T4S=7?:ith restriction in e%tension4 rotation is to the side of the stuc; condyle

)natomy .7ST4


77/390

Jerte$ral distance#inger width9inger )idth

Translating rle testingTranslation TestingTranslation to)ards the R = "idebending */alpate for restrictionResists translation to the * ++O"idebent R reistance ++O"idebent * ease

/lace inde% fingers on articular pillarsTranslate * and R + feel for restrictionRepeat in fle%ion and e%tensionRemember4 lesions )ill translate more symmetrically in their (fle%ione%tension-position of ease/ractice this )hile standing tooK


78/390

HJL) prep cer(ical*inear Traction"tretch*o)er cervical muscles/osterior cervical muscles

.erpendiclar Stretch' HJL) .reparation

' "er(ical Stretching

HJL) .reparation' "er(ical Stretching'Bilateral Stretch

"A'I !scle 4nergy

/atient supine8oc at head of table"upport occiput in palmInde% finger over articular pillar of segment4 on side of "> resistance9le% or e%tend to restriction at segment using opposite handIntroduce side bending to restriction by translating the segment to restrictionRotate to restrictionInstruct patient to move head into one position of ease (sidebending- againstcounterforce'old 0+3 sec.Rela%4 Reset4 Repeat4 Rechec;

=ncremental !o$iliGation


79/390

#se one hand to gently cup the occiput'old cervical spine in neutral#se the thumb and inde% (or middle finger- of other hand to contact the articularpillars Add fle%ion or e%tension to resistance

Add cephalad traction (to disengage the facets-

9or C+6B Introduce rhythmic translatory motion in the direction of resistance9or AAB Introduce rhythmic rotatory motion left S right

4xamples:

:ith restriction in fle%ion4 rotation is to the side of the freely moving condyle

:ith restriction in e%tension4 rotation is to the side of the stuc; condyle

9le%ing+ condyles bac;)ardChin left*eft rotation

Right sidebending* condyle moves bac;R condyle stuc;$"rightRleft

Chin rightRight rotation*eft sidebendingR condyle moves bac;* condyle stuc;$"leftRright

Cannot translate *Cannot sidebend RCannot rotate ** condyle stuc; anteriorR condyle moves posterior9ree movements+$%tension4 *eft sidebending4 Right rotation8iagnosis+ $"leftRright

Cannot translate RCannot sidebend *Cannot rotate RR condyle stuc; anterior* condyle moves posterior9ree movements+$%tension4 Right sidebending4 *eft rotation8iagnosis+ $"rightRleft

$%tending+ condyles for)ard

Chin left*eft rotation


80/390

Right sidebendingRight condyle moves for)ard*eft condyle stuc;9"rightRleft

Chin rightRight rotation*eft sidebending*eft condyle moves for)ardRight condyle stuc;9"leftRright

Cannot translate *Cannot sidebend RCannot rotate *R condyle stuc; posterior

* condyle moves anterior

Cannot translate RCannot sidebend *Cannot rotate R* condyle stuc; posteriorR condyle moves anterior

9ree movements9le%ion4 Right sidebending4 *eft rotation8iagnosis+ 9"rightRleft

9ree movements9le%ion4 *eft sidebending4 Right rotation8iagnosis+ 9"leftRright

7) !4Introduce side bending to restriction by translating the segment to restrictionRotate to restrictionInstruct patient to move head into one position of ease ( 9$4 R4 or ">- againstcounterforce

'old 0+3 sec.Rela%4 Reset4 Repeat4 Rechec;


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7): Left "ondyle


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Indirect + 'elps integrate changes9unctional Methods*igamentous Articular Release

7) /U* test and treat

&. !+A *ateral Translation TestB Translation Resistance *eft or Right )ith the 'eadin 9le%ion or $%tension =O 8iagnosis

Resists Translation from the left to)ard the right )hile the head is fle%ed.Thereforeit resists *eft sidebending"idebent Right at the !A re?uires Rotation *eft.Therefore the diagnosis isB $"RR* ($"Rleft-

"tep B 8irection of Condylar Motion )ith 'ead in /osition of TranslationResistance+9le%ion is the 'ead /osition in )hich Translation Resistance :as $ncountered

+Condyles must be able to move posterior for 'ead 9le%ion to occur

"tep 0B 8irection of Condylar Motion )ith 'ead in /osition of TranslationResistanceIn 'ead 9le%ed /osition the condyles are moving posterior.The *eft Condyle must move posterior for *eft Rotation to occur.Therefore4 the Right ,oint is the restricted ,oint. It is stuc; anterior.

TreatmentBGoalB Carry the left occipital condyle for)ard on the atlas9orce must be directedB+"uperior to disengage the facet ,oint+Medial S Anterior to follo) the plane of the facetsThe Resulting Lector is To)ard the !pposite !rbit

Treatment !ption IIBGoalB Carry the right facet of the atlas for)ard under the occiputCaudad 'and ThrustsB on Right *ateral Mass of the Atlas

Treatment !ption IIB!ccipital 'and 8isengages S *ocali@esB

"uperior to disengage the facet ,oint9le% to locali@e"idebend Right to stabili@e occiput (9ryettes 0rd *a)-9orce must be directedB

Atlas 'andB Medial S Anterior to follo) the plane of the facets and rotate the atlasleft


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Stretches smmaryTI/"KIf the nec; is hypertonic do something else first9inding the >arrier

8ont lose barrier )hen pt ta;es a breath/atient rela%ationK$ngage resistance slo)ly and actually feel )hat you need to*oc;ing out the segmentThrust

%%%eural"ympathetic/arasympathetic9luids

*ymphaticLenous>iomechanical

Lisceral/ain


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%%%"ympatheticRib Raising

%%%eural Treatments/arasympathetic"uboccipitalCranial"acral

#lid TreatmentsThoracic Inlet

Anterior cervical fascia&st rib

Abdominal diaphragm/elvic diaphragm"oft tissue effleurage

$iomechanic treatmentTreatment of associated regional somatic dysfunction

Treatment of distal but associated somatic dysfunction

.ain TreatmentsTreatment of areas directly involved )ith pain may be indirectly involved in any ofthe other case considerations

Jisceral treatmentsTreatment of affected visceraabdomen

Three regions

three treatmentsthree mintes


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>ron@e level treatment

"ympathetic/arasympathetic

Lenous*ymphatic

#rom a chief complaint' case considerations9indings"ystems

chief complaint we$

pnemonia we$Rib 0B >iomechanical influence on the function of the pulmonary tree

May impact sympathetic chain at region related to lung


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"ase "onsideration in the U5 system"ympathetic T&F+*T&F+&& Didney4 Adrenal4 GonadsT&+* >ladder4 /rostate

/arasympatheticLagus to Didneys"acral /le%us to >ladder4 /rostate

9luids/elvic diaphragm and abdominal diaphragm

Lena cava

Cisterna chyliThoracic inlet

>iomechanicalRectus abdominus tender pointsInnominate dysfunction"acral 8ysfunction/elvic diaphragm

/ainIliolumbar ligament

Trigger pointsGenitofemoral nerve

/sychosocialIncontinence>/'Chronic #TI


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SympatheticT&F+&& Didney4 Adrenal4 GonadsT&+* >ladder4 /rostate

Remember diaphragm and its role as thoracolumbar modulator'istory of *$ in,ury4 potentially activating the *$ sympathetic levels*o) bac; strains4 especially long+standing

.arasympathetic

Lagus to Didneys"acral /le%us to >ladder4 /rostate

>ac;ground cervical dysfunction>ac;ground lo) bac; pain4 sacral dysfunction


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#lid/elvic diaphragm and abdominal diaphragm

Lena cavaCisterna chyliThoracic inlet

8iaphragmatic dysfunction#nderlying innominate dysfunction9irst ribThoracic inlet

chapmans reflexes/redictable anterior and posterior fascial tissue te%ture abnormalities assumed to bereflections of visceral disease

Liscero+somatic refle%


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chapmans reflexes/redictable anterior and posterior fascial tissue te%ture abnormalities assumed to bereflections of visceral disease

Liscero+somatic refle%

Biomechanical'Rectus abdominus tender pointsInnominate dysfunction"acral 8ysfunction/elvic diaphragm

/soas Tension8iaphragm tension*umbar dysfunction"acral and pelvic influence on pelvic diaphragm*o)er e%tremity influence on sacrumpelvis

.ain' trigger pointsIliolumbar ligamentTrigger pointsGenitofemoral nerve

Consider referred pain from myofascial tissuesConsider tender points

Maybe chief complaint related


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referred iliolm$ar pain

JisceralDidney ptosis8ysfunction of ureter8ysfunction of bladder

'eart

RRR)ithout murmur"creen positive for thoracic region"can and "eg. 8ef. T2 9R"r

AB &- #pper Respiratory Infection 4 - Rib /ain4 0-"omatic 8ysfunction of thethoracic region/B &- !MTB 9/R to thoracic dysfunction improved symmetry of motion and patientcomfort after the treatment4 - MedicationB ...4 0- /t. $ducation

case considerations!MM Case Considerations X& point e%tra creditYB>iomechanicalB thoracic dysfunction affects rib function and rib pain

ervousB"ympatheticB T2 is at the level for innervation to the lungs


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/arasympatheticB o related X"ince you only have one ob,ective finding that doesnot relate to this >ut if cervical )ere your regions this )ould be filled out instead of"ympathetic/ainB T2 related afferent fibers may be mediating part of the pain9luidB the biomechanical influence on ribs could decrease respiratory effectiveness

and thus fluid drainage.LisceralB e%t year

7(er(iew"ub,ectiveB 'istory ta;ing&F minutesBChief Complaint'istory of /resent Illness/ertinent Revie) of "ystems (if unsure4 as; facultyfello)sTAsMa,or 8iagnoses + Medical"urgical8ecide )hich se?uence is applicable to this persons complaint

!b,ective + /hysical e%am"creen (&F minutes-B 8o a focused screen. Thin; of regions anatomically related tothe chief complaint."creen the regions that are part of the se?uence you choseB#pper half of the body*o)er half of the body

"canB $ach student scans region screenedMar; identified segments )ith red dots*oo; for segmental tissue te%ture changesB bogginess4 fibrotic4 ropey4 coolhot4 etc.Record and communicate scan results in the ob,ective section

9or $%tremities + #se )hat you have learned so far#$B scapulothoracic eval. S t%*$B hip restrictor eval. S t%

"egmental 8efinitionB8efine Rotational aspectsB Rotation "idebending 9le%ion$%tension+ 8efineTranslational aspectsB

A+/4 *eft+Right4 Ceph+Caud + Respiratory preference (ribs-B Inhalation$%halation

Relate the findings on your patient to comorbidities + CL4 Resp4 GIG#4 etc.9luid congestion"ympathetic facilitation/arasympathetic imbalance/ain

)ssessmentAssessmentB

&. Medical 8iagnosis(es-

. "omatic 8ysfunction8esignate Region that you diagnosed that demonstrated evidence of somatic


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dysfunction as indicated by the ob,ective findings

$%ampleB"B lo) bac; pain!B *o)er lumbar soft tissue resistance increased and resists rotation right

AB &-lo) bac; pain (or *+" "train-- "omatic dysfunction of the lumbar region

.lan:&. 8iagnosticsB *ab4 Imaging4 etc.. !MTBConsider se?uencing of treatment :hich "omatic 8ysfunction should be treatedfirst and )hy&. 8esignate S record method(s- used in each region. It is not necessary to repeatthe information already recorded in the !b,ective sectionK.ote patient response to overall treatment

0.Medication4 if indicated2. /t. $ducation+ Things to avoid+ Things to do3. Referral bac; to their physician for further $valuation S Treatment$tc.5. etc.

Types of Somatic Dysfnctionremember yello)

Lymphatics smmary*ymphatics are the !verflo) system of the body.*ocal drainage or lac; thereof is only one component in the e?uation of fluid buildup.Dey /rincipleB Any bloc;age /ro%imal to the e%cess fluid )ill inhibit its drainage.


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How is an osteopathic diagnosis different from an allopathic diagnosisof the lower extremity?Motions=Gross vs. fineRelationships

=Interrelatedness of subtle dysfunction on rest of functioning organism

Diagnosis & Treatment:Upper Half of the Body

Anterior RibsThoracolumbar JunctionCervicothoracic JunctionThoracics !ther Ribs"capulothoracic ArticulationCraniocervical Junction CraniumCervicalsRest of #pper $%tremity

Lower Half of the Body Diagnosis and Treatment Seqence&. 'ip restrictors (some of )hich cross the *umbo+sacral ,unction-. /ubic bone dysfunction0. "uperior innominate shear (1innom. upslip1-2. *umbar dysfunction (esp. *3 or4 less often *2-3. "acral dysfunction

5. Innominate dysfunctions (other than upslip-6. Iliopsoas (including thoraco+lumbar ,unction4 appro%. T&&+*-7. !ther *o)er $%tremity 8ysfunction

!ost "ommon SD9ibular head (antpost-Tibial rotation (inte%t-Talus (antpost-Calcaneal (inversioneversion-8ropped cuboidnavicular

Metatarsal dysfunction


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"ommon #i$lar n%=:raps around posterior part of fibula="ensitive to trauma4 fracture or posterior fibular head dysfunction=In,ury at ;nee can produce )ea;ness of dorsifle%ors and foot drop (supplies(motor-

==anterior++deep fibular+== lateral


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= /regangionic fibers arise from T&&+*= "hared )ith innervation of pelvic organs via least splanchnic n. and lumbarsplanchnic n.= May e%plain Chapmans points along IT> for colon problems= *&+0 dermatomal pattern anterior thigh

Lymphatic Drainage' Sperficial=Abdominal )all belo) umbilicus=Gluteal region belo) iliac crest=/erineum (part of anal canal4 superficial &0 of penis4 vulva4 vagina-="uperficial part of thighs4 legs4 feet=8rainage into superficial nodes in inguinal and femoral triangle thendeep tonodes and channels arond femoral (ein in pper thigh

Lymphatic Drainage' Deep=/arallel path)ays along iliac veins to cysterna chyli= 8rains to thoracic duct (left lymphatic duct-= Receives drainage from left side of head and nec;4 posterior and upper lobe of leftlung.


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#nctional )natomy: *nee'')rticlar' femr and ti$ia8ouble condylar comple% synovial ,oint formed by femoral condyles and tibial

plateau

Medial and lateral semilunar cartilage (menisci- provide stability4 smoothness andresistance to pressure

Medial condyle longer than lateral. /rovides for=posterolateral glide )ith internal rotation=anteromedial glide )ith e%ternal rotation

femr and patella ,oint=Gliding ,oint=Tendon of ?uadriceps femoris incorporates patella and attaches to tibial tuberosity/atellar tendon refle% at *2


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)rticlar' medial and lateral collateral ligaments*ateral"tabili@ation against lateral displacementot attached to lateral meniscus

Medial"tabili@ation against medial displacement

Attached to medial meniscusMa;es medial cartilage more susceptible to medial displacement or t)isting

#nctional )natomy: *nee'')rticlar crciate ligaments

Anterior attaches to anterior tibia/revents e%cessive anterior tibial glide/osterior to posterior tibia/revents e%cessive posterior tibial glide

Somatic dysfnction of -neeminor motionsB+anterior posterior glide+mediallateral glide+anteromedial or posterolateral glide (associated )ith inte%t rotation-


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.roximal Ti$iofi$lar /oint= "eparate synovial ,oint at the ;nee= !bli?ue angulation+ lateral anterior to medial posterior position=Motions at pro%imal and distal fibula are reciprocal=8orsifle%ion + foot+ moves distal fibula posteriorly4 pro%imal fibula glides anterior

=!pposite )ith plantar fle%ion (fibular head posterior-

)n-le'')rticlar+ 8istal tibia and talus

+ An;le mortice includes distal fibula (lateral malleolus-

+ Transverse a%is of an;le ,oint not parallel to transverse a%is of body4 foot isnormally in slight abductiono pure supination or pronation of the foot

an-le motions"upination $?uivalentInversion/lantar 9le%ion

Adduction

/ronation $?uivalent$version8orsifle%ion

Abduction


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Lateral )n-le Ligaments00

Anterior talofibular ligment/osterior talofibular ligamentCalcaneofibular ligament

5enerally disrpted in an-le in(ersion or spination sprainGrade I ++anterior talofibularGrade II +add calcaneofibularGrade III+ all lateral ligments torn

!otions of the foot

Abduction$%ternal rotation of the tibia

Anteromedial glide at the ;nee

AdductionInternal rotation of the tibia/osteorlateral glide at the ;nee


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#nctional )natomy: #oot''!scles and Tendons ' !yofascial'posterior and lateral maleols

Achilles tendon+ attaches to posterior calcaneus from common origin ofgastrocnemius and soleus mm.

/osterior to Medial Malleolus/osterior Tibial Tendon9le%or 8igitorum *ongus9le%or 'allicicus *ongus1Tom4 8ic;4 and 'arry1

#oot )nterior Tendons

Anterior Tendons

Anterior Tibialis Tendon+ "upports longitudinal arch$%tensor 8igitorum *ongus$%tensor 'allicus *ongus1Tom4 8ic;4 and 'arry1

Tendons .osterior to Lateral !alleols9ibularis >revis9ibularis *ongus+ "upports transverse arch


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Longitdinal )rches*ateralCalcaneus4 cuboid4 and metatarsals 2 and 3

MedialTalus4 navicular4 three cuneiforms4 metatarsals &+0

Trans(erse )rch' whats the msclar spport% what $ones ma-e pthis archCuboid4 navicular4 three cuneiforms4 and metatarsal bones

Muscular "upport++/eroneus (fibularis- longus inferiorly4 and tibialis anterior (firstcuneiform and first metatarsal


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.lantar Ligament Spport/lantar Aponeurosis*ong plantar ligament"hort plantar ligament

"pring ligament

!otions of the foot9orefoot inversion (supination strain-Talus glides posterolaterally at talocalcaneal ,oint relative to the navicular

9orefoot eversionTalus glides anteromedially

Scan 2*nee3!rthopedic Testing+Medial and lateral collateral ligament+/atellar grind

+8ra)er test+*achmans sign

!otions: *44 and a $nch of other


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D$$=*ateralMedial=Anterior/osterior=Anteromedial ($ET rot-/osterolateral (IT rot-

9ibular head motion

*ateral Malleolar Motion

"train to Interosseous Membrane

An;le Motion+Talotibial motion+"ubtalar motion+Intertarsal motion

#oot motionavicular bone dysfunction/lantar glide and medial rotation (inversion-

Cuboid bone dysfunction/lantar glide and lateral rotation (eversion-

Cuneiform dysfunction/lantar glide )ithout rotation

+Tarsal metatarsal ,oint motion=Generally less motion at the nd metatarsal=Minor motions are anteriorposterior glide4 mediallateral glide4 internale%ternalrotation glide


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Scan: Hindfoot and !idfoot"ubtalarInversion and $version at Talar Calcaneal

avicular/lantar position and tendernessMedial and inferior glideCuboid/lantar position and tenderness*ateral and inferior glide

Cuneiforms/lantar position/lantarinferior glide

MetatarsalsAdduction4 Abduction4 /lantar4 8orsifle%ion4 RotationMotion and /osition

#nctional )natomy: S$talar /ointTalocalcaneal Joint"econdary glide motions areInversion$version

Also Talonavicular glidesAnteromedial (eversion-/osterolateral (inversion-

L4 Scan Seqence00


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Dnee+Internal$%ternal Tibial torsion+9ibular 'ead

Midshaft

+Interosseous

An;le9oot+Talus+"ubtalar+Tarsal+Metatarsal

I 9 I T " T MI found in the stone4 the mallet

Diagnosis of 4xtremities: 5eneral S")'Comparison is made to opposite e%tremity

"can is guided byBChief complaint or"creening e%am findings in absence of complaint

"can chec;s for/osition andMotion

Diagnosis of 4xtremities: 5eneral' S")6amed in ease+Medial "ternoclavicular anterior and superior+/osterior 9ibular head

8ysfunction in secondary glides of ,oint (mainly-

Treatment 7ptions8irect9ind resistance position of ,oint

Move through that resistance by muscle energy4 springing4 or thrusting

Indirect9ind position of ease in all planes and phase of respirationRefine position as release occurs

Scan: *nee

/ositionB Tibial tuberosityMotionB Tibial rotation


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Scan: )n-le

/ositionB Talar domeMotionB Talar glide

#oot

4picondyles of the femr+/alpate the patella+"lide your thumb lateral to the outside of the ;nee+"lide bac; to the patella and move medially

Ti$ial t$erosity8 .atella how to do it? 9H?


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"it4 ;nee fle%ed+/lace hand on the anterior aspect of the ;nee (1;nee cap1-+Move fingers inferiorly until encountering a boney prominence

+#sed to determine mediallateral rotation of the tibia

+Continue do)n the tibia until reaching the medial malleolus

Ti$ial .latea+/lace thumbs on both sides of the patella+"lide inferiorly into soft4 ,oint space+Continue to palpate inferiorly until you feel bone

; )ngle*ess than &3 degrees in men

*ess than F degrees in )omen

+Increase in angle can result from e%cessive an;le pronation

+Increase in angle may result in patellofemoral syndrome


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Head of the fi$la' 9H4


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Calcaneo+fibular lig./osterior talo+fibular lig.

"alcanes where is it9ind the medial and lateral malleoli

8rop inferiorly onto the calcaneus (heel of foot-

a(iclar & "$oid 9H4


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"nieforms & !etatarsals+>egin palpation ,ust pro%imal to the metatarsal phalangeal ,oint.+$%plore all 3 metatarsal bones+The 3th metatarsal bone has a lateral prominencenamed the tuberosity of the 3th metatarsal+*ocate the &st metatarsal and move pro%imally to palpate a small ,oint bet)een themedial cuneiform and the &st metatarsal+Move onto the cuneiform and e%amine the bony structures more laterally (middleand lateral cuneiforms-

Screen8Scan for Somatic Dysfnction in the Lower 4xtremity+8irected at region of interest as identified by the patient (chief complaint-

+Assessed bilaterally for comparison of motion

+9ocus is usually on smaller secondary motions

+Attention must be given to ,oints above and belo) complaint area (at least-

+If dysfunction appreciated in neighboring regions must be further e%amined.

9hat is .ostral Balance?Continual adaptation of muscular tone in response to gravitational influences(among others-.


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D4#=46 7ptimal .ostral Balance/erfect distribution of body mass around the center of gravity4 )ith compressiveforces on spinal dis;s balanced by ligamentous tension.

!steopaths have agreed that the center of *0 is the center of average4 passive4standing adults. *i;e this guy.

9hy is .ostral Balance so =mportant?+/osture is but the formal e%pression of the balance of po)er e%isting bet)een theenvironmental force of gravity and the strength of the individual. Thus anydeterioration of posture indicates that the individual is losing ground in her contest

)ith the environmental forces of gravity.1


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+9asciaB sheets of fibroelastic connective tissue throughout the body

2 1crossover sites1 )here fascial tension can occur>ased on Junctiontransition areasCranium

Thora%/elvis

And the diaphragms that bridge them+Tentorium+Thoracic inlet+Abdominal diaphragm+/elvic diaphragm+Torsions of these fascial path)ays can compromise neural vascular flo).

$mbryologically4 transition @ones are )ea;er4 and more e%posed to acute orrepetitive trauma.

compensatory and noncompensatory mechanismsCommon compensatory patternB a series of myofascial torsions that are compatible

)ith physiologic function

on+compensatoryB not rotated in alternating directions+Compromises respiratory+circulatory integrity of body+Can be traumatically induced+:ill eventually display congestive systems

types of alignment' case considerationsI8$A*4 DH/'!TIC4 9*AT >ACD4 ":AH >ACDThe complaint of 1ec; /ain sho)s up in t)o different biomechanical environmentsin these t)o patients. (image & and -

:hich one is more li;ely to complain of tension headaches


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:hich one is more li;ely to be able to ta;e a deep breath &

:hich one might be more structurally vulnerable to case of pneumonia "tructure of the spine )ill affect the function of the thoracic viscera+ heart4 lungs.Can this person ta;e good deep breaths Can the heart efficiently provide enough

blood to the circulatory system.otential .ostral =nflencing History=Congenital>irth historyCongenital scoliosis (see appendi%-"houlder dystocia4 torticollis4 hip dysplasia

=Trauma"urgeriesIn,uriesChildbirthB vaginal4 c+sectionDneehip replacement/ostural imaging studies

=Medical 8iagnosisAsthma!steoporosispenia

=Activities!ccupationK")imming

:eight lifting

Diagnosis: .hysical 4xamLisual Inspection B loo; at your patients criticallyRememberB )ords have )eight thoughts are things

"tructural $%amB+gravity line+landmar;s

/alpatory $%am+screen and scan


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Landmar- re(iew+>ase of !cciput+"capular "pine+Inferior angle+Iliac crest4 /"I"

=="tanding fle%ion+Dnees+Arches of feet

gra(itational lineGravitational *ine "hould pass throughB&. $%ternal auditory meatus

. *ateral head of the humerus

0. Center of the >ody of *0

2. Anterior third of the sacral base

3. Greater trochanter

5. *ateral condyle of the ;nee

6. *ateral malleolus

A' >" T*M


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7) ,nction: $ase of occipt' case considerations= >iomechanicsB tonic nec; refle%es cranial strain patterns= euralB C e%it s;ull in this neighborhood= 9luidB vertebral artery to interior of cranium sagital sinus4 transverse sinus as

venous drainage= LisceraB C" sinuses= "8 at this level can induce+ 'ypertonicity of postural muscles+ 8isturbances of facial symmetry4 e?uilibrium and locomotor deficits.

CsB &F4&&4&

"T ,nction: scaplae case considerations= 1relatively mobile cervical spine meets relatively rigid thoracic spine.1=>iomechanicsB #$+shoulder girdle influences=="IT" muscles=="erratus anterior4 rhomboids4 pectoralis etc=euralB brachial ple%us4 phrenic4 vagus upper sympathetic chain=9luidB thoracic inlet=LisceraB headnec;4 heart4 lungs4 etc

TL ,nction: 2@Ath3 ri$s iliac crests case considerations

=8iaphragmK==>iomechanicsB s;eletal attachments==9luidB Aorta4 Lena Cava4 A@ygous fluid pump of body


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==LisceralB esophagus4 lo)er GI4 liver4 ;idney==euralB phrenic visceral sympparasymp considerations

=/ostural imbalance of *o)er >ody (biomechanics-==TonicB Iliopsoas4 *4 erector spinae

==/hasic or InhibitedB Rectus abdominus

Lm$o'sacral ,nction:='ori@ontal alignment of "acral >aseB==*!T" of implications into posture4 pain.=9luidsB inguinal nodes4 pelvic diaphragm=euralB lumbo+sacral ple%us4 pelvic and sacral splanchnics=LisceraB lo)er GI4 reproductive4 urinary considerations>iomechanicsB NNNNN NNNNN NNNNNN

!scle phys re(iew: alpha gamma motor neron re(iew= A disturbance of M" function initiates a series of events beginning )ithstimulation to mechanoreceptors and nociceptors4 resulting in afferent neural

activity...

= The final common path)ay is the alpha motor neuron that stimulates the musclefiber to contract4 and through the gamma system4 the muscle spindle to adapt4resulting in alteration in muscle tone. = Chronic dysfunction feeds the afferent loop4more nociception and abnormal mechanoreceptor information4 perpetuatingongoing aberrant muscle tone.8isturbanceResults in alteration4 adaptation

Interruption and reprogramming of the vicious cycle contribute to improvement ofoverall muscle tone and balance.


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:hat this means=J!> "$C#RITH

Short Leg SyndromeCondition in )hich there is an anatomical or functional leg length discrepancy thatresults in

&. "acral >ase unleveling. vertebral side bending A:AH and rotation T!:AR8" lo) side0. Innominate rotation and side shifting to)ards long leg2. and more

$arth is mostly even+ $yes level )ith the hori@onB pelvic imbalance can manifest

further a)ay (headaches- because of the bodys ability to compensate and adapt toimbalance

>et)een earth and eyes is )here the compensation and dysfunction can occur.

/elvis dropped to)ard the short leg"pine curves conve%ly a)ay from the short leg+ shoulders compensate opposite topelvis

"ommon #indings in Short Leg syndrome&. "acral >ase unleveling B lo)er on the side of the short leg.

. Anterior innominate rotation on the side of the short leg+ Iliacus contracture canbe source of this.0. /osterior innominate rotation on the side of the long leg.2. *umbar spine )ill sidebend a)ay and rotate to)ard the side of the short leg3. Iliolumbar ligaments may become stressed on the side of the short leg.5. "I ligaments may become stressed on the long leg side.

9hat happens when mscle pairs exert ne(en pll on fondation?how to fix?+Muscle ImbalanceB

+#pper Cross "yndrome+*o)er Cross "yndrome


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:AH" T! 9IE 9undamental /rinciples of Muscle Imbalances"ensory motor balance trainingB more here in year K"tretching of short4 tight (tonic- muscles 9IR"T."trengthening )ea;4 inhibited (phasic- muscles $ET.

Aerobic conditioning

!verall GoalsB=Maintenance of enhanced M" functional capacity=achieved by appropriate manual med intervention and a continual e%erciseprogram

Upper and Lower "ross Syndrome' C@ postral im$alance% Uppercross

/!"T#RA* IM>A*AC$+ /ostural muscles tend to)ards 'H/$Rtonicity+ dynamic muscles (phasic- tend to)ards 'H/!tonic overstretch.

Tonic = Tight = "hort = "trong/hasic = )ea; = *ong

+Asymmetry in tensions of agonist+antagonist pair+Imbalance can be in the coronalfrontal plane4 as in scoliosis... oranteriorposterior4 as in upper and lo)er cross.

#pper crossB anterior compartment tightens )hile the posterior torso )ea;ens .Lower cross follows similar general patterning+ /atterns4 not absolutes.+ /ostural imbalance of *o)er >ody (biomechanics-= TonicB Iliopsoas4 *4 erector spinae4 tensor fascia lata4 adductors4 piriformis4hamstrings.= /hasic or InhibitedB Rectus abdominus4 gluts (ma%4 med4 mini- obli?ues4 vastusmedialus4 lateralis4 tibialis anterior

+"tretching of short tight muscles

quiqz flch card osteo.doc

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