OPP 1 Study Guide Written Exam 3 Fall 2023_Thomas Fotopoulos.pptx

Study Guide for OPP 1 Written Exam 3 Fall 2023 Osteopathic Concepts • For ANY disease state, the patient must be STABLE before performing OMT • Cardiovascular, pulmonary, GI, GU, etc. • New onset of chest pain or shortness of breath is not a time for OMT! • Somatic dysfunction can occur anywhere i...

Study Guide for OPP 1 Written Exam 3 Fall 2023 Osteopathic Concepts • For ANY disease state, the patient must be STABLE before performing OMT • Cardiovascular, pulmonary, GI, GU, etc. • New onset of chest pain or shortness of breath is not a time for OMT! • Somatic dysfunction can occur anywhere in the body at • Sympathetics levels • Paraysmpathetic levels • Soma (not autonomic related) • Viscerosomatic reflexes occur at • Sympathetics levels • Parasympathetics levels • Facilitated segments ONLY occur at Osteopathic Concepts: Please know • Remember, sometimes muscle hypertonicity, contraction, spasm can be caused by direct irritation of the what is overlying the muscle: • For example, if there is a stone in the ureter, it may cause the psoas to become hypertonic (Positive Thomas test) • For example, if there is appendicitis, it may cause the psoas to become hypertonic (Positive Thomas test) • Translation to the right=left side-bending, translation to the left=right side-bending • Osteomyelitis may occur invasive orthopedic procedure/IV drug use • Tight hamstrings may cause a posterior innominate rotation • Tight quadriceps may cause an anterior innominate rotation • Goal of ME in innominate somatic dysfunction treatment is to restore joint motion • Lumbar spine will side-bend towards the long leg side and rotate towards the short leg side (Type I like mechanics) Osteopathic Concepts: Please know • A reversible dextroscoliosis or levoscoliosis means there is NO SAGITTAL COMPONENT present (no flexion or extension component) so it follows Fryette Type 1 mechanics. A dextroscoliosis would have the convex side pointing to the right, therefore indicating a neutral side-bending left, rotating right pattern for the vertebrae. Therefore, for example, a dextroscoliosis from T4-T6 would have all of the vertebra being neutral, side-bent left, rotated right. • A left lateral convexity means the vertebrae are side-bent right. A right lateral convexity means the vertebrae are side-bent left • When treating a group dysfunction with OMT, go for the apex (middle) of the group curve. Example: • L1-L3, go for L2 • L1-L5, go for L3 Somatic Dysfunction • Somatic dysfunction is an impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements. • Diagnosed by T.A.R.T. • T: Tissue Texture Changes • A: Asymmetry • R: Restriction of motion • T: Tenderness • Always named for the way it likes to go • In axial spine, the reference point is the superior/anterior aspect of the vertebra • Not all somatic lesions are somatic dysfunctions. Fractures, sprains, degenerative processes, and inflammatory processes are not somatic dysfunctions. Palpating Somatic Dysfunction ACUTE CHRONIC • Recent history (injury) • Sharp or severe localized pain • Warm, moist, sweaty skin • Long-standing • Dull, achy diffuse pain • Cool, smooth, dry skin • Boggy, edematous tissue • Erythematous • Possible atrophy • Fibrotic, ropy feeling tissue • Pale/skin pallor • Local increase in muscle tone, contraction, spasm, increased muscle spindle firing • Normal or sluggish ROM • May be minimal or no somatovisceral effects • Decreased muscle tone, contracted muscles, sometimes flaccid • Restricted ROM • Somatovisceral effects more often present “Old is cold, hot is not” Remember, post ganglionic sympathetic fibers lead to tissue texture changes such as hypertonicity, moisture, erythema, etc. Dorsal horn of the spinal cord is where somatic and visceral afferent nerves synapse giving a viscerosomatic reflex 4 Principles of Osteopathic Medicine Principle 1: Principle 2: Principle 3: Principle 4: The body is a unit; the person is a unit of mind, body, and spirit (gastric ulcer causes thoracic tissue texture changes) The body is capable of self-regulation, selfhealing, and health maintenance (healed fracture) Structure and function are reciprocally interrelated Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function 5 Osteopathic Models • Biomechanical (structural, postural) • Anatomy of muscles, spine, extremities; posture, motion • OMT directed toward normalizing mechanical somatic dysfunction, structural integrity, physiological function, homeostasis • Neurological • Emphasizes CNS, PNS and ANS that control, coordinate and integrate body functions • Proprioceptive and muscle imbalances, facilitation, nerve compression disorders, autonomic reflex and visceral dysfunctions, brain/CNS dysfunctions • Respiratory/circulatory • Emphasizes pulmonary, circulatory and fluid (lymphatic, CSF) systems • Lymphatic techniques • Metabolic/Nutritional • Regulates through metabolic processes • Behavioral (psychobehavioral) • Focuses on mental, emotional, social and spiritual dimensions related to health and disease TYPES OF MOTION terms describing motion Orientation of Superior Facets Region Orientation of Inferior Facets Facet Mnemon Orientati ic on Backward BUM , Upward, Medial Region Thoracic Backward BUL , Upward, Lateral Thoracic Anterior, AIM Inferior, Medial Lumbar Backward BM , Medial Lumbar Cervical Cervical Facet Mnemoni Orientati c on Anterior, AIL Inferior, Lateral Anterior, AL Lateral Fryette Law 1  When side-bending is attempted from neutral (anatomical) position, rotation of vertebral bodies follows to the opposite direction.  Typically applies to a group of vertebrae (more than two)  Occurs in a neutral spine (no extreme flexion or extension) NO SAGITTAL COMPONENT  Side-bending and rotation occur to opposite sides  Side-bending precedes rotation  Side-bending occurs towards the concavity of the curve  Rotation occurs towards the convexity of the curve  Diagnosed as a Type I dysfunction N T2-6 RRSL T2-6 N RRSL T2-6 N SLRR Fryette Law 2  When side-bending is attempted from nonneutral (hyperflexed or hyperextended) position, rotation must precede side-bending to the same side.  Typically applies to a single vertebra  Occurs in a non-neutral spine (flexion or extension of spine present) SAGITTAL COMPONENT  Side-bending and rotation occur to same sides  Rotation precedes side-bending  Rotation of the vertebra occurs into the concavity of the curve  Diagnosed as a Type II dysfunction F E T4 E RLSL T4 E SLRL  May be described as traumatic injury T4 E SRL 12 Tri-positional Diagnosis • Determine which transverse process of the vertebra is posterior: this is the side of rotation (should test with rotational component) • Keep the side of rotation/posterior transverse process in your mind as you move to the next step Tri-positional Diagnosis • Monitor the posterior transverse process. • Then, have the patient flex and extend to see if the posterior transverse process moves more anteriorly (in other words: evens out, improves, becomes more symmetrical, gets better) with either flexion or extension • If a posteriorly rotated process moves anteriorly with flexion: it is F Rx Sx • If a posteriorly rotated process moves anteriorly with extension: it is E Rx Sx • If rotational component does not change with either maneuver (or gets worse with flexion and extension), it is neutral: N Sx Ry Translational Motion • Translation • If a segment translates to the right, this induces left sidebending • If a segment translates to the left, this induces right sidebending L R This segment is translating to the left, which is inducing right side-bending Tri-Positional Diagnosis Screen the region. Identify a transverse process that feels posterior. (Posterior TP = X) Have patient flex and extend his/her spine. evaluate if the asymmetry improves Improves In Flexion FRSX No Improvement NSYRX Neutral (Type I) Non Neutral (Type II) Improves In Extension ERSX Rule of 3’s • T1-3: spinous processes project posteriorly therefore the tip of the spinous process is in the same plane as the transverse process of that vertebra • T4-6: spinous processes project slightly downward, therefore the tip of the spinous process lies in a plane halfway between that vertebra’s transverse processes and the transverse processes of the vertebra below it • T7-9: spinous processes project moderately downward, therefore the tip of the spinous process is in a plane with the transverse process below it • T10 follows rules of T7-9 • T11 follows rules of T4-6 • T12 follows rules of T1-3 Indirect and Direct treatment • If INDIRECT treatment used: exaggerate/augment the dysfunction • If DIRECT treatment used: engage the barrier/reverse the dysfunction Indirect Technique • Somatic dysfunction is exaggerated or augmented • Somatic dysfunction is taken the way it likes to go • Restrictive barrier is disengaged • Dysfunction is taken into position of injury • Uses inherent forces • Uses a compressive, tractional, or torsional component Direct Technique • Somatic dysfunction is taken the way it does not like to go • Restrictive barrier is engaged • Uses external forces Examples of Indirect Techniques • Counterstrain • Facilitated Positional Release (FPR) • Balanced Ligamentous Tension Technique (BLT) • Functional Technique • Myofascial Release (may also be direct) • Cranial (may also be direct) • Still Technique (combined indirect and direct) • Initial positioning of Still Technique set up is indirect • Ending positioning of Still Technique is direct Counterstrain: Definition of Tender Point • Specific discrete areas of local tenderness • No radiation of pain • Can occur in areas where somatic dysfunction reduces motor firing thresholds [Denslow] • Usually unilateral, but can be bilateral • Can be found both anteriorly and/or posteriorly • Area of patient’s pain may not be where the physician finds the tenderpoint • Location of specific tenderpoints are constant from one patient to another • Suggests a strong anatomic basis for their location Counterstrain: Steps of Treatment • Assess the “this is a 10” pain level • Maintain finger contact at all times (NOT PRESSING FIRM constantly, only monitoring!)(***continuous monitoring) • this is to monitor tension, not to treat • Find the position of comfort • Retest by pressing with contact finger • This is a passive treatment • Hold it for 90 seconds (that’s the time for ALL counterstrain points, including ribs) • monitor tension and response • Return patient to neutral position SLOWLY!! • Recheck pain level • should be a 3 or less • The only time you press firmly is when finding the point, repositioning the point. All other times you are keeping you contact finger on point to just monitor location. Anterior Lumbar Counterstrain Points Tender Point Location Treatment Position Acronym Dr. will stand on the same side of the tender point for AL1 and AL5. For AL2-4, stand on the opposite side. Patient is supine, knees and hips flexed to shorten tissues around the tender point AL1 Medial to ASIS Flex to L1, side bend (ankles) toward, knees (pelvis) toward which rotates torso and L1 away F ST RA AL2 Medial to AIIS Flex to spinal level, side bend (ankles) away, knees (pelvis) away which rotates torso and lumbar segment toward F SA RT AL3 Lateral to AIIS Same as above (AL2) F SA RT AL4 Inferior to AIIS Same as above (AL2) F SA RT AL5 Anterior, superior aspect of pubic ramus, lateral to symphysis pubis Flex, side bend (ankles away, knees (pelvis) toward which rotates torso and lumbar segment away F SA RA Nicolas. Atlas of Osteopathic Techniques. 2E. FPR • Body part in NEUTRAL position (flatten the curve/spine) • COMPRESSION applied to shorten muscle/muscle fibers (some cases may have TRACTION instead) • Place area into EASE of motion (INDIRECT) for 3-5 seconds • Return body part to neutral • THIS TECHNIQUE IS INDIRECT!!!! Still Technique • Tissue/joint placed in EASE of motion position (augments the somatic dysfunction) • Compression (or traction) vector force added • Tissue/joint moved through restriction (into and through the restrictive barrier) while maintaining compression (or traction) and force vector • THIS TECHNIQUE GOES FROM INDIRECT TO DIRECT!!!! Examples of Direct Techniques • Myofascial Release (May also be indirect) • Soft tissue • Articulatory • Muscle Energy • High velocity, low amplitude (HVLA) • Springing • Cranial (may also be indirect) • Still Technique (combined indirect and direct) • Initial positioning of Still Technique set up is indirect • Ending positioning of Still Technique is direct Muscle Energy Technique Postisometric Relaxation Reciprocal Inhibition • Procedure - • Procedure Dysfunctional Structure Positioned at Feather Edge of Direct Barrier - (Positioning is in All Three [3] Planes of Motion) Dysfunctional Structure Positioned at Feather Edge of Direct Barrier (Positioning is in All Three [3] Planes of Motion) - Physician Continuously Monitors Dysfunction - Physician Continuously Monitors Dysfunction - Patient is Instructed to GENTLY Push AWAY From the Barrier - Patient is Instructed to GENTLY Push TOWARD the Barrier - Physician Resists Patient’s Effort for 3 - 5 Seconds - - Patient is Instructed to Relax Physician Resists Patient’s Effort for 3 - 5 Seconds - Physician Repositions Patient to Feather Edge of New Barrier - Patient is Instructed to Relax - Physician Repositions Patient to Feather Edge of New Barrier - Repeat 3 - 5 Times or until Maximum Improvement - Passively Reposition to Neutral After Last Effort - Repeat 3 - 5 Times or until Maximum Improvement - Passively Reposition to Neutral After Last Effort - Recheck Area of Dysfunction for Change Sympathetic levels Head and Neck: T1 – T4 Heart: T1– T5/T6 Respiratory: T1 –T6/ T2 – T7 Esophagus: T2 – T8 Upper GI Tract: T5 – T9 – Stomach, Liver, Gall Bladder, Spleen, Pancreas, Duodenum Middle GI Tract: T10 – T11 – Pancreas, Duodenum, Jejunum, Ileum, Ascending colon, Right Transverse Colon, Kidney, Upper Ureter, Gonads Lower GI Tract: T12 – L2 – Left Transverse Colon, Descending Colon, Sigmoid colon, Rectum, Prostate, Bladder, Lower Ureter Appendix: T10 – T11 Kidneys: T10 – T11 Adrenal Medulla: T10 Upper Ureters: T10 – T11 Lower Ureters: T12 – L1 Bladder: T12 – L2 Gonads: T10 – T11 Uterus & Cervix: T10 – L2 Erectile tissue: T11 – L2 Prostate: T12 – L2 Arms: T2 – T8 Legs: T11 – L2 Parasympathetic Levels • Vagus Nerve (OA, AA, C2) Trachea, esophagus, heart, lungs, liver, gallbladder, stomach, pancreas, spleen, kidneys, proximal ureter, small intestine, ascending colon, and transverse colon up to the splenic flexure • S2-S4 Distal to the splenic flexure of the transverse colon, descending colon, sigmoid colon, rectum, distal ureter, bladder, reproductive organs, and external genitalia . • Variations: Ovaries & Testes Vagus Nerve S2-S4 Peripheral Sympathetic Supply • Sympathetic Supply to Upper Extremity Vasculature • T2 to T8 levels • Sympathetic Supply to Lower Extremity Vasculature • T11 to L2 levels ****There are no parasympathetic supply to the upper or lower extremities Viscerosomatic Considerations • T10-T11 • Kidney • Upper Ureters • T11-L1 • Lower Ureters • T11-L2 • Lower Extremities • T12-L2 • Left Colon • Bladder • Prostate 32 Iliolumbar Ligaments • Originates from the iliac crest and inserts on the transverse process of L4 and L5. • Refers pain to the groin, SI region, and lateral thigh. • Located on both sides of the lower lumbar spine acts as guide wires to stabilize the lower segments. (Increases stability at the lumbosacral junction) • Commonly Strained in Traumatic Injuries • *** First Ligament to Become Tender with Lumbar Postural Changes • Tender Area 1” Superior and Lateral to the PSIS • Responds well to O.M.T. Lumbarizati on Sacralization Disc Load and Positioning • Sitting with Poor Posture Applies the Greatest Load Possible • Load on L3 of a 70 kg Person in Kilograms 35 Disc Herniation • Posterolateral Lumbar Disk Herniation Most Common • Narrow Posterior Longitudinal Ligament • See X+1 Rule • Most Common Levels • L4-L5 • L5-S1 36 Disc vs. Deficit • X+1 Rule • Herniation at Disc X Affects Nerve Root X+1 EX: Herniation @ L3L4 Affects L4 Nerve Root • Nerve Root X Will Have Already Exited the Foramina and Will be Unaffected (Usually***) Disc vs. Deficit Neuro exam • motor = muscles responsible for foot inversion • DTR = patellar reflex • sensory = medial aspect of leg and foot Neuro exam • motor = extension of extensor hallucis longus m. against resistance • no reflex! • sensory = lateral side of leg and dorsum of foot • “Walk on your heels” Neuro exam • motor = muscles responsible for eversion • achilles tendon reflex • sensory = lateral malleolus and lateral aspect of foot • “Walk on your toes” Herniated Disc Herniated Nucleus Pulposis • Posterolaterally is most common for herniation of lumbar disk • Also, may occur laterally or centrally • Sudden “acute” pain, painful numbness • Increased intra-abdominal pressure accentuates symptoms • Most commonly L5-S1 & L4-L5 Babinski Reflex Positive Babinski Reflex Indicates Upper Motor Neuron Problems Negative Reflex=Plantar reflex down going (not called a negative Babinski as indicated in picture) 43 Straight Leg Raise Test A Positive Test Does Not Necessarily Indicate a Herniated Disc 0 - 35 degrees - Some Tension on the Sciatic Nerve 35 - 70 degrees - Maximally Involves Sciatic Nerve > 70 degrees - Most Likely Joint Pain 44 Straight Leg Raise Test • Patient in the supine position • The hip is medially rotated and adducted and with the knee extended, the examiner flexes the hip until the patient complains of pain in the back of the symptomatic leg 45 Bragard Test Patient’s leg is lowered toward the table, until pain free Patient’s ankle is dorsiflexed If the dorsiflexion of the ankle reproduces the symptoms, the test is positive indicating 46 Contralateral SLR Test (Crossed SLR Test) Physician lifts patient’s uninvolved leg A positive test is when the patient experiences radicular symptoms down the involved leg. 47 FABERE Test (Patrick Test) *** This tests for pathology of the SI joint or hip Ober’s Test • Assessment for contracture/tightness of iliotibial band or tensor fascia latae • Dr stabilizes hip and knee • With knee flexed, extend hip • Gently allow thigh to adduct toward table • Considered positive if thigh cannot adduct past midline Trendelenburg Test • Assessment of gluteus medius muscle strength • Pt stands on one foot while flexing opposite knee and lifting foot off floor • Gluteus medius muscle on opposite side of flexed knee should abduct leg, keeping pelvis level • Considered positive if pelvis tilts toward side of flexed knee • Not to be confused with hip-drop test, which assesses ability of lumbar vertebrae to sidebend *** You would watch how the patient walks, paying attention to their swing phase of walking. If the patient’s left hip drops during the swing phase, you look for somatic dysfunction with the right gluteus medius. Hip Drop Test • Assessment of lumbar spine compensation to sacral base declination (Screening test) • Patient bends one knee without lifting heel off floor and allowing hip to drop downward • Negative= Iliac crest on the unsupported side drops 20-25 degrees, and there is a smooth lumbar curvature toward the weight bearing side of the body. Indicates normal side-bending ability of the lumbar and thoracolumbar spine • Positive=Iliac crest does not drop 20-25 degrees on the non-weight bearing side and there is a poor lumbar spinal curve towards the weight bearing side. A positive test indicates that the lumbar and/or thoracolumbar spine has difficulty side- 51 Thomas Test • Test for psoas muscle tension/hypertonicity (hip flexion contracture) • Patient lies supine and holds uninvolved knee to their chest, while allowing the involved extremity to lie flat. • Holding the knee to their chest flattens out the lumbar lordosis and stabilizes the pelvis. • If the iliopsoas muscle is shortened, or a contracture is present, the lower extremity on the involved side will be unable to fully extend at the hip (ie the thigh and popliteal region will not lay flat on the table 52 Hoover Test Tests for Malingerers (Drug seekers, someone looking for secondary gain, like drug seekers) Patient Supine Physician Holds Beneath the Patient’s Calcaneus When the patient tries to raise one leg, there should be contralateral pressure on the opposite heel, if that person is trying. 53 “Red Flags” Lumbar Pain • Age 50 years or older • Previous history of cancer • Unexplained weight loss • Failure to improve with 1 month of therapy • No relief with bed rest L1–L5 “Neutral” Dysfunctions Seated, Post-Isometric Relaxation Ex: L2 N SL RR • The patient is seated at the end of the table. The physician stands to the side opposite to the rotational component of the dysfunction. • The patient places the right hand behind the neck and the left hand on the right elbow. • The physician passes the left arm under the patient's left arm and grasps the patient's right upper arm (Fig. 10.109). • The physician's right hand monitors the spinous processes of L2 and L3 or the L2–L3 interspace as the left arm and hand flex and extend the patient's torso (white arrow, Fig. 10.110) until L2 is neutral in relation to L3. (Fig. 10.109) (Fig. 10.110) L1–L5 “Neutral” Dysfunctions Seated, Post-Isometric Relaxation Ex: L2 N SL RR • The physician's right hand monitors the transverse processes of L2 and L3 to localize side bending and rotation as the left arm and hand position the patient's torso to the edge of the right side bending (white arrow, Fig. 10.111) and then the left rotation barrier (white arrow, Fig. 10.112). • The physician instructs the patient to turn or pull the right shoulder back to the right (black arrow, Fig. 10.113) while the physician's left hand applies an unyielding counterforce (white arrow). The force of the patient's contraction is the least amount necessary to produce a palpable muscle twitch at the segmental level that the physician is monitoring. (Fig. 10.111) (Fig. 10.112) (Fig. 10.113) L1–L5 “Neutral” Dysfunctions Seated, Post-Isometric Relaxation Ex: L2 N SL RR • This isometric contraction is maintained for 3 to 5 seconds, and then the patient is instructed to stop and relax. • Once the patient has completely relaxed, the physician, keeping L2 neutral, repositions the patient to the edge of the right side bending barrier (white arrow, Fig. 10.114) and left rotation barrier (white arrow, Fig. 10.115). • Steps 6 to 8 are repeated three to five times or until motion is maximally improved at the dysfunctional segment. • Motion of the dysfunctional segment is reevaluated to assess the effectiveness of the technique. (Fig. 10.114) (Fig. 10.115) L1–L5 “Extension” Dysfunctions Seated, Post-Isometric Relaxation Ex: L2 E SR RR • The patient is seated, and the physician stands to the left of the patient (side opposite to the rotational component of the dysfunction). • The patient places the right hand behind the neck and the left hand on the right elbow. (Variation: the patient may place the hands behind the neck and approximate the elbows anteriorly.) • The physician passes the left arm over or under the patient's left arm and grasps the patient's right upper arm (Fig. 10.116). • The physician's right hand monitors the spinous processes of L2 and L3 or the L2–L3 interspace to localize flexion and extension as the physician's left hand positions the patient's trunk to the edge of the restrictive flexion barrier (Fig. 10.117). (Fig. 10.116) (Fig. 10.117) L1–L5 “Extension” Dysfunctions Seated, Post-Isometric Relaxation Ex: L2 E SR RR • The physician's right hand monitors the transverse processes of L2 and L3 to localize side bending and rotation as the physician's left hand repositions the patient's trunk to the edge of the left side bending barrier (Fig. 10.118) and left rotation barrier (Fig. 10.119). • The physician instructs the patient to sit up and gently pull the right shoulder backward (black arrow, Fig. 10.120) while the physician's left hand applies an unyielding counterforce (white arrow). The force of the patient's contraction is the least amount necessary to produce a palpable muscle twitch at the segmental level the physician is monitoring. (Fig. 10.118) (Fig. 10.119) (Fig. 10.120) L1–L5 “Extension” Dysfunctions Seated, Post-Isometric Relaxation Ex: L2 E SR RR • This isometric contraction is maintained for 3 to 5 seconds, and then the patient is instructed to stop and relax. • Once the patient has completely relaxed, the physician repositions the patient to the edge of the left side bending (white arrows, Fig. 10.121), left rotation (Fig. 10.122), and flexion barrier (Fig. 10.123). • Steps 6 to 8 are repeated three to five times or until motion is maximally improved at the dysfunctional segment. • Motion of the dysfunctional segment is reevaluated to assess the effectiveness of the technique. (Fig. 10.121) (Fig. 10.122) (Fig. 10.123) SACRAL ANATOMICAL AXIS Transverse axis • Superior: • the cranial primary respiratory mechanism creates motion around this axis • Middle: • sacral base anterior and posterior (FB/BB) occur around this axis • Postural • sacrum flexes and extends around this axis (sagittal plane) • Inferior: • the innominates rotate around this axis relative to the sacrum Standing Flexion Test • Patient standing with feet flat on floor and shoulder width apart • Physician monitors the inferior aspect of patient’s PSIS • Patient forward bends maximally • Positive: side PSIS moves more cephalad at the end range of motion • Purpose: identifies side of sacroiliac somatic dysfunctions • “Gold Standard” Test for iliosacral SD ASIS Compression Test • Apply a posterior-medial pressure on one ASIS while stabilizing the other. • Imagine aiming the pressure toward the SI joint. • Repeat the test on the other side. • The restricted side is the positive side. Seated Flexion Test • Patient seated on stool with feet flat on floor and shoulder width apart • Physician monitors the inferior aspect of patient’s PSIS • Patient forward bends maximally • Positive: side PSIS moves more cephalad at the end range of motion • Purpose: identifies side of sacroiliac somatic dysfunctions • “Gold Standard” Test for sacroiliac SD Somatic Dysfunction of the Pelvis • Anterior Innominate Rotation • Posterior Innominate Rotation • Innominate Up-slip (Superior Innominate Shear) • Innominate Down-slip (Inferior Innominate Shear) • Innominate Out-flare (ABducted Innominate) • Innominate In-flare (ADducted Innominate) Innominate Rotation Anterior Posterior • + standing flexion (on side of the dysfunction) • ASIS Compression test + (on side of dysfunction) • Inferior ASIS (on side of the dysfunction)-may also be described as caudad and slightly medial • Superior PSIS (on side of the dysfunction)-may also be describes as cephalad and slightly lateral • Superior ischial tuberosity (on side of the dysfunction) • Shallow sacral sulcus (on side of the dysfunction) • Equal iliac crest height • + standing flexion (on side of the dysfunction) • ASIS Compression test + (on side of dysfunction) • Superior ASIS (on side of the dysfunction)-may also be described as cephalad and slightly lateral • Inferior PSIS (on side of the dysfunction)-may also be described as caudad and slightly medial • Inferior ischial tuberosity (on side of the dysfunction) • Deep sacral sulcus (on side of the dysfunction) • Equal iliac crest height • Medial malleolus inferior (long leg) (on side of the dysfunction) • Superior medial malleolus (short leg) (on side of the dysfunction) Innominate Outflares/Inflares Outflare (ABducted) Inflare (ADducted) • + standing flexion (on side of the dysfunction) • ASIS Compression test + (on side of dysfunction) • ASIS lateral (on side of the dysfunction) • PSIS medial (on side of the dysfunction) • Distance from ASIS to umbilicus increased on dysfunctional side (is more lateral) • ASIS further from midline • + standing flexion (on side of the dysfunction) • ASIS Compression test + (on side of dysfunction) • ASIS medial (on side of the dysfunction) • PSIS lateral (on side of the dysfunction) • Distance from ASIS to umbilicus decreased on dysfunctional side (is more medial) • ASIS closer to midline • Narrow sacral sulcus (on side of the dysfunction) • Wide sacral sulcus (on side of the dysfunction) Inferior Innominate Shear Downslipped Innominate Innominate Shears Superior Innominate Shear Upslipped Innominate • + standing flexion (on side of the dysfunction) • ASIS Compression test + (on side of dysfunction) • Superior ASIS (on side of the dysfunction) • Superior PSIS (on side of the dysfunction) • Superior iliac crest height (on side of the dysfunction) • Superior pubic tubercle (on side of the dysfunction) • Superior ischial tuberosity (on side of the dysfunction) • Superior medial malleolus (on side of the dysfunction) • Sacrotuberous ligament lax (on side of the dysfunction) • + standing flexion (on side of the dysfunction) • ASIS Compression test + (on side of dysfunction) • Inferior ASIS (on side of the dysfunction) • Inferior PSIS (on side of the dysfunction) • Inferior iliac crest height (on side of the dysfunction) • Inferior pubic tubercle (on side of the dysfunction) • Inferior ischial tuberosity (on side of the dysfunction) • Inferior medial malleolus (on side of the dysfunction) • Sacrotuberous ligament tight (on side of the dysfunction Pubic Shears Superior Pubic Shear Inferior Pubic Shear • + standing flexion (on side of the dysfunction) • ASIS Compression test + (on side of dysfunction) • Superior pubic tubercle/ramus (on side of the dysfunction) • Ipsilateral inguinal ligament tense and tender • ASIS may be even or may be superior (on side of the dysfunction) • PSIS may be even or may be inferior (on side of the dysfunction) • Findings may look similar to a posteriorly rotated innominate • + standing flexion (on side of the dysfunction) • ASIS Compression test + (on side of dysfunction) • Inferior pubic tubercle/ramus (on side of the dysfunction) • Ipsilateral inguinal ligament tense and tender • ASIS may be even or may be inferior (on side of the dysfunction) • PSIS may be even or may be superior (on side of the dysfunction) • Findings may look similar to an anteriorly rotated innominate Anterior Innominate Rotation Muscle Energy • Patient supine, stand/sit on dysfunctional side facing cephalad. • Use your medial hand to stabilize the contralateral ASIS. • Place patient’s leg against/on your shoulder. Cup PSIS with your lateral hand. • Flex hip and knee on side of dysfunction to rotate the innominate posteriorly to the restrictive barrier. • Instruct the patient to gently push their knee into your shoulder (they are extending their hip) for 3-5 seconds while you resist their effort. (Patient using hamstrings) • Have the patient relax, then further flex the patient’s hip to rotate the innominate posteriorly into the new restrictive barrier. • Repeat 3-5 times. • Reassess. Posterior Innominate Rotation Muscle Energy 1 • Patient supine, stand on dysfunctional side, facing caudad. • Use your medial hand to stabilize the contralateral ASIS. • Have the patient lay near the edge of the treatment table, allowing their leg and the ischial tuberosity to hang off the table. • Place your hip against the patient so they do not feel like they are going to fall off of the table. • Place your hand on the patient’s thigh just proximal to the knee. Gently push the patient’s leg toward the floor into extension to rotate the innominate anteriorly to the restrictive barrier. • Instruct the patient to gently push their knee toward the ceiling (they are flexing their hip) for 3-5 seconds while you resist their effort. (Patient using quadriceps) • Have the patient relax, then further extend the patient’s leg to rotate the innominate anteriorly into the new restrictive barrier. • Repeat 3-5 times. • Reassess. Posterior Innominate Rotation Muscle Energy 2 • Patient prone, stand opposite the dysfunctional side, facing toward the treatment table. • Use your cephalad hand to induce a force into the table at the PSIS. • Place your caudad hand just proximal to the knee and extend the hip to rotate the innominate anteriorly to the restrictive barrier. • You can have the patient flex their knee to decrease resistance. • Instruct the patient to gently pull their leg toward the table (they are flexing their hip) for 3-5 seconds while you resist their effort. (Patient using quadriceps) • Have the patient relax, then further extend the patient’s hip to rotate the innominate anteriorly into the new restrictive barrier. • Repeat 3-5 times. • Reassess. Innominate In-flare (Adducted) Muscle Energy • Patient supine, stand opposite of the dysfunctional side facing cephalad. • Use your cephalad hand to stabilize the contralateral ASIS. • Flex and ABduct the patient’s hip and knee and place the patient’s foot on the table near the other leg. • “Figure 4” or “frog leg” position • Instruct the patient to gently push their knee toward the ceiling for 3-5 seconds while you resist their effort. • Have the patient relax, then further ABduct the patient’s leg into the new restrictive barrier. • Repeat 3-5 times. • Reassess. Innominate Out-flare (Abducted) Muscle Energy • Patient supine, stand on dysfunctional side facing toward the patient’s midline. • Grasp the patient’s knee with the caudad hand, and the medial aspect of the ipsilateral PSIS with the cephalad hand. • Flex the patient’s hip and knee, ADduct the knee across the midline, engaging the restrictive barrier. • Instruct the patient to gently ABduct their knee for 3-5 seconds while you resist their effort. Gently apply a lateral force to the PSIS. • Have the patient relax, then further ADduct the patient’s leg into the new restrictive barrier. • Repeat 3-5 times. • Reassess. Superior Pubic Shear Muscle Energy • Patient supine, with the ipsilateral ischial tuberosity near the edge of the treatment table. Allow the leg to hang off the table. • Stand between the table and the patient’s leg, facing cephalad. • Use your medial hand to stabilize the opposite ASIS. • ABduct the knee to gap the pubic symphysis. • Gently push the patient’s leg toward the floor into extension until you reach the restrictive barrier. • Instruct the patient to gently push their knee toward the ceiling for 3-5 seconds while you provide a resist their effort. • Have the patient relax, then further flex and ABduct the patient’s leg into the new restrictive barrier. • Repeat 3-5 times. • Reassess. Inferior Pubic Shear Muscle Energy • Patient supine, stand on dysfunctional side facing cephalad. • Flex the hip and knee and ABduct the thigh to gap the pubic symphysis. • Place the patient’s knee against your chest. Use your cephalad hand to cup the ASIS and your caudad hand to grasp the ischial tuberosity. • This rotates the innominate posteriorly to bring the pubic symphysis superiorly. • Instruct the patient to gently push their knee into your chest for 3-5 seconds while you resist their effort. • Have the patient relax, then further flex and ABduct the patient’s leg into the new restrictive barrier. • Repeat 3-5 times. • Reassess. Innominate Up-slip (Superior Innominate Shear) Muscle Energy • Patient supine, stand at the foot of the table facing cephalad. • Grasp the lower extremity just proximal to the ankle. • Internally rotate and slightly flex the hip, and ABduct to about 20°. • Apply traction until the restrictive barrier is reached. • Instruct the patient to pull their hip cephalad for 3-5 seconds while you resist their effort. • Have the patient relax, then add traction to the patient’s leg until the new restrictive barrier is met. • Repeat 3-5 times. • Reassess. Muscle Energy treatment of Pubic Shears • An inferior pubic shear is treated like an Anterior Innominate rotation with the addition of ABduction. • A superior pubic shear is treated like a Posterior Innominate rotation with the addition of ABduction. Psoas syndrome • Condition that results from hypertonicity/spasm of the psoas muscle • Usually the result of being in a position that allows prolonged shortening of the psoas followed by its sudden lengthening. Examples: • • • • • • working at a desk or crawlspace road trips, plane trips sitting in a soft easy chair or recliner bending over from the waist for a long period of time weeding in the garden trauma (strain) • May be precipitated by overuse, such as doing sit-ups with the lower extremities fully extended • Creates a neuromuscular imbalance that results in psoas muscle hypertonicity. Psoas muscle and lumbar spine are affected. • Patient may complain of pain in the thoracolumbar region and/or the anterior hip, thigh, or groin. Psoas Syndrome • Organic Causes of psoas tension of spasm must be ruled out by history and/or physical examination and special tests: • • • • • • • • • • Femoral bursitis Arthritis of the hip Appendicitis Diverticulosis of the colon Ureteral calculi Prostatitis Cancer of the descending or sigmoid colon Salpingitis Psoas abscess Etc. • Viscerosomatic reflex (ureteral calculi as an example) • Direct irritation (ie, psoas fascia touches the sigmoid colon and ureters) • Ureteral calculi as an example Diagnosis • Patient may stand slightly flexed at the waist and side-bent toward the dysfunctional side (hypertonic psoas muscle) • Motion testing of the affected leg will resist hip extension • Tender points will be found at Psoas Major muscle • ⅔ of the distance from the ASIS to the midline • May also find at Psoas Minor and Iliacus if involved • May be found at contralateral Piriformis muscle. • Special test: Thomas Test will be positive on side of hypertonic psoas muscle Diagnosis • Positive Thomas test • Psoas tender point (TP) • Possibly contralateral piriformis tender point TP • May or may not have sciatic type pain down the opposite leg • Central low back pain • May be significant Psoas Syndrome • The key somatic dysfunction initiating or perpetuating psoas syndrome is believed to be a type II (non-neutral) somatic dysfunction (F Rx Sx) usually occurring in the L1 or L2 vertebral unit, where “x” is the side of side-bending of the somatic dysfunction. If this key somatic dysfunction remains, the patient’s symptoms may progress to full-blown psoas syndrome. Osteopathic structural exam findings indicative of this syndrome include: • The key, nonneutral (type II) somatic dysfunction at L1 and/or L2 • Sacral somatic dysfunction on an oblique axis, usually to the side of lumbar sidebending • Pelvic shift to the opposite side of the greatest psoas spasm • Hypertonicity of the piriformis muscle contralateral to the side of greatest psoas spasm • Sciatic nerve irritation on the side of the piriformis spasm • Gluteal muscular and posterior thigh pain that does not go past the knee, on the side of the piriformis muscle spasm Special Tests • Hip Drop Test • Thoracolumbar/Lumbar Side-Bending Abnormality • Trendelenburg Test • Gluteus Medius Weakness • FABERE/Patrick Test • SI joint or hip pathology • Ober Test • Tensor fascia latae tightness • Straight Leg Raising (SLR) Test • Herniated Lumbar Disc (L1-L5, S1) • Contralateral Straight Leg Raising • Test Herniated Lumbar Disc (L1-L5, S1) Special Tests • Bragard Test • Herniated Lumbar Disc (L1-L5, S1) • Thomas Test • Hip Flexion Contracture (Psoas Muscle Hypertonicity) • Babinski Reflex • Upper Motor Neuron Pathology • Hoover Test • Malingerer (such as drug seeker) One Gait Cycle is considered from heel contact of one foot through heel contact of thatinSAME foot again • Double support the gait cycle begins at heel strike Phases of Gait: Stance & Swing: A - G • Double Just look at the right heel……A thru support G in the gait cycle begins at heel strike Pathologic Gaits • Antalgic Gait: (gait to avoid pain) A limp is adopted to avoid pain on weight bearing structures (hip, knee, ankle). Typically the stance phase is shortened relative to the swing phase on the affected side (e.g. knee pain on the right decreases the stance phase of the right leg) • Ataxic Gait: An unsteady, uncoordinated walk, a wide base of support. Often due to cerebellar problem (e.g. intoxication, stroke). Can also be due to sensory ataxia (e.g. peripheral neuropathy) • Fenestrating Gait: short, accelerating steps are used to move forward, often seen in patients with Parkinson’s Disease ** (i.e. Shuffling Gait) Pathologic Gaits • Hemiplegic Gait: involves unilateral flexion and circumduction of the hip due to weak extensors. Will se ipsilateral upper extremity flexion. Common post stroke. • Spastic Gait (diplegic): walk in which legs are held close together and move in a stiff manner, bilaterally. (e.g. scissor gait in patients with cerebral palsy) • Trendelenburg Gait: an abnormal gait caused by weakness of the abductor muscles of the lower limb (gluteus medius and gluteus minimus) • Steppage Gait (Foot Drop Gait): gait in which the advancing foot is lifted higher than usual so that it can clear the ground (decreased/absent dorsiflexion). Seen in L5 and fibular neuropathies leading to weakened dorsiflexion. Coronal Plane: Scoliosis Location & Naming of Curves Scoliosis Location •Scoliotic curve is named for: •Direction – Right or Left •Dextroscoliosis: convexity to right •Levoscoliosis: convexity to left •Pattern – Single, double or junctional •Location – Thoracic – Single Lumbar – Single Thoraco-lumbar double (most common) Junctional thoraco-lumbar Junctional cervicothoracic (rare) Examples: Right thoracic curve of 70 degrees Right thoraco-lumbar curve of 70 degrees Double major curve of 75 degrees (R thoracic, L lumbar) Scoliosis First thing evaluate for reversibility of curvature Functional Scoliotic Curve o Have patient try to sidebend towards side of rib hump. If it reduces the rib hump- it is called a “functional” scoliosis Structural Scoliotic Curve o Remains fixed with positional changes o GIVE PATIENT HOME EXERCISE WWW.SCOLIOSIS.ORG DYNAMIC SCREENING TEST Heel Lift Guidelines 1.The heel lift should be applied to the side of the short leg 2.The final lift height should be ½ - ¾ of the measured leg length discrepancy, unless there was a recent sudden cause of the discrepancy (hip fracture, prosthesis) then lift the full amount 3.The “fragile” patient (elderly, arthritic, osteoporotic, acute pain) should begin with a 1/16” (1.5 mm) heel lift and increase 1/16” every two weeks 4.The “flexible” should begin with 1/8” (3.2mm) heel lift and increase 1/8” every two weeks 5.A maximum of ¼” may be applied to the inside of the shoe (if >1/4” is needed, then this must be applied to the outside of the shoe 6.Maximum heel lift possible = ½”. If more is needed, an ipsilateral anterior sole lift extending from heel to toe should be used in order to keep the pelvis from rotating to the opposite side • For example, if a patient has an 8 mm leg length discrepancy chronically (Long Term), your goal is to lift to 4mm Heel lift Guidelines • Final lift height should be ½ – ¾ of the measured discrepancy • If acute discrepancy (i.e., hip fracture), lift full amount • Start with 1/8” heel lift, then increase by 1/8” every two weeks • Frail patients should start with 1/16” heel lift, then increase by 1/16” every two weeks. • Heel lift treatment is considered clinically complete when the patient has reduced painful symptoms. Short Leg syndrome • Anatomical or functional • Signs/symptoms • • • • • • Sacral base unleveling Anterior innominate on side of short leg Posterior innominate on side of long leg L-spine will side-bend away from and rotate towards short leg Lumbosacral (LS) angle will increase Stress on iliolumbar ligaments then SI ligaments • Heel life can be used to help prevent osteoarthritis in a person with short leg syndrome Treating Lymphatics (Thoracic inlet/outlet has to be cleared/opened/treated BEFORE ANY other lymphatic treatment) *** Another way of saying this is that you have to open myofascial pathways at the transition zones ****Thoracic inlet/outlet components: • Supraclavicular space • 1st rib Treatment examples include: • Anterior cervical fascia release • Thoracic inlet myofascial release • Pectoral Traction The “Why” behind the Indications for Lymphatic Treatments • Remove mechanical barriers to lymphatic flow • Promote or augment lymphatic flow • Increase reabsorption of fluids • Increase circulation and respiration • Decrease proteins in the interstitium • Drain toxins • Assist tissue regeneration • Stimulate immune function • Diminish sympathetic tone • Retain treatment gains Good luck!!!! • For ANY clarifications, please refer back to all the Lecture/Lab/Reading assignments • All concepts are cumulative: for example, Fryette principles, direct/indirect technique set up, indication/contraindications, etc. • Thank you for being a great class!!!!