OPP OMS 1 Sem 2

what are the axes of SI and IS motion?

• SI → sacral flex/extend @ middle transverse (S2)

• IS → innominate/pelvic @ inf. transverse axis (S3)

• NOTE: respiratory/cranial @ sup. transverse (S2)

what are the landmarks for a pelvic diagnosis?

• Iliac crest

• ASIS + PSIS → thumbs inf. (height + width)

• pubic tubercle → sup. surface

• medial malleolus → thumbs inf.

what are the indications for CS?

• lawrence jones, 1955

• acute injury

• neural component (hyper shortened)/ hypertonic

• hospitalized/ frail

  • other treatment uncomfortable

what are the absolute contraindications for CS?

• lack of consent

• can’t tolerate position (acute fracture, torn ligament) or exacerbates

• neuro symptoms manifest

• vascular /neuro syndrome (basilar insufficiency, neuroforaminal compromise)

• degenerative spondylosis w/ local fusion

what are relative contraindications to counterstrain?

• pt. can’t relax/apprehension/can’t tolerate

• upper cervical hyper rotation/extension w/ vertebral a. disease or lig. instability, dens malformation, osteoporosis

• severe acute rheumatological flare

• CT disease, arthritis, parkinson’s

what are the steps of CS?

• contact tender pt. → establish 10/10

• place pt. in position of ease until tenderness reduced by 70%

• hold 90 seconds

• passively to neutral

• reassess (dec. 70%)

psoas CS?

• 2/3 from ASIS to midline, deep

• hip flexion, SB lumbar spine towards, some hip ER

• F ST er

iliacus CS?

• 1/3 from ASIS to midline, deep post. lat.

• hip flexion, hip ER + knee flexed

• F ER

low ilium CS?

• sup. ilio pubic eminence

• ipsilateral hip flexion

• F

inguinal CS?

• lat. pubic tubercle

• thigh flex w/ good over evil, ipsilateral lower leg pulled lat. for IR of affected hip

• F ADD IR

AL1 + AL5 CS?

• stand on same side, pt. supine w/ hips + knees flexed

• flex to level, side bend (ankles), knees (pelvis) toward → rotates torso + segment away

• AL1 → F St RA (StaR)

• AL5 → F SA Ra (SaRa)

AL2, AL3, AL4 CS?

• stand on opposite side, pt. supine w/ hips + knees flexed

• med., lat., inf. to AIIS

• flex to level, SB away → rotates torsos + segment toward

  • AL2 → SB @ ankle

  • AL3/4 → SB @ knees

• F SA RT

tender vs trigger

• tender:

  • locally tender + jump response

  • NO pain pattern + NO radiating pain

  • in muscle, tendon, etc.

• trigger:

  • locally tender + jump response

  • pain pattern + radiating pain

  • in muscle + in taut band of tissue

  • twitch response

  • dermographia

how to lateralize the pelvis + sacrum?

• standing flexion test (pelvis), seated flexion test (sacrum)

  • lateralize to side that is most superior

• ASIS compression test (post. med)

  • lateralize to side that is more stiff

how do you diagnose the pelvis?

• assess PSIS, ASIS (+ midline distance), pubic tubercle, medial malleolus

• record relative to lateralized side (i.e L lateralization → left ASIS sup. or inf.)

what are the characteristics of an anteriorly rotated innominate SD?

• on lateralized side → ASIS inf., PSIS sup., MM long, PT slight inf.

• on opposite side → ASIS sup., PSIS inf., MM short

what are the characteristics of a posteriorly rotated innominate SD?

• on lateralized side → ASIS sup., PSIS inf., MM short, PT slight sup.

• on opposite side → ASIS inf., PSIS sup., MM long

what are the characteristics of an innominate outflare + inflare SD?

• outflare (rotated out) → (on lateralized side) ASIS lat. + PSIS med. towards lateralized side

• inflare (rotated in) → (on lateralized side) ASIS med. + PSIS lat. towards lateralized side

what are the characteristics of a superior and inferior pubic shear?

• sup. shear → ASIS sup. MM short, PSIS sup., PT sup.

• inf. shear → ASIS inf., MM long, PSIS, inf., PT inf.

indications for ME?

• myofascial SD (dec. hypertonicity, lengthen muscle, stretch), SD of articular origin (mobilize joint, improve ROM)

• improve circulation/respiration, inc. muscle tone

absolute contraindications for ME?

• fracture/dislocation in region

• lack of consent/cooperation

• lack of SD

relative contraindications for ME?

• moderate/severe strains

• severe osteoporosis

• severe illness (post. surg./ICU)

innominate PIR ME anterior rotation SD treatment?

• pt. supine, stand on involved side

• flex, ER, ABduct hip

• pull ischial tuberosity ant

• pt. push against shoulder (3-5x, 3-5 sec, 3-5 oz, 2 sec. relax)

innominate PIR ME posterior rotation SD treatment?

• pt. supine, stand on involved side

• hold opposite ASIS to stabilize

• leg + ischium off table → leg extended

• pt. push thigh upwards

innominate PIR ME inflare SD treatment?

• pt. supine, stand on opposite side holding contralateral hip

• flex hip + knee (foot above opposite knee) → ABduct hip (should feel @ ASIS)

• pt. push knee up/inwards

innominate PIR ME outflare SD treatment?

• pt. supine, stand on involved side (monitor PSIS)

• flex hip + knee w/ foot on knee → ADduct knee (should feel @ PSIS)

• pt. push knee out

innominate PIR ME shear SD treatment?

• pt. supine

• ABduct + IR leg to gap SI joint

  • sup. shear → lean back for traction @ SI joint, pt. hike hip up

  • inf. shear → compress @ SI joint, pt. push towards you

how to lateralize for sacral/ SI joint diagnosis?

• seated flexion test → thumbs under, eye level

  • higher PSIS → lateralize

• ASIS compression test → posterior push (dominant eye over)

  • more stiff → lateralize

what are landmarks for sacral/SI joint diagnosis?

• sacral base

• PSIS

• sacral sulci → thumbs medial to PSIS, deeper/ant. sulci (+)

• ILA → palm on drop off, go lateral, deeper/ant. ILA (+)

what are the special tests for sacral diagnosis? what do positive results determine?

• BBT/sphinx test → (+) not improved/worsened symmetry

• lumbar spring → (+) lack of spring

• extension/backward torsion

diagnosis of forward sacral torsion?

• axis is opp. of lateralization (seated flexion test)

• R on R → left sulci + ILA both ant.

• L on L → right sulci + ILA both ant.

diagnosis of backwards sacral torsion?

• axis is opp. of lateralization (seated flexion test)

• R on L → right sulci + ILA both post.

• L on R → left sulci + ILA both post.

what is the movement of L5 relative to forward and backward torsions?

• forward (neutral) → L5 follows Type 1 (NSRRL/NSLRR)

• backward (nonneutral) → L5 follows type 2 (FSSRR/FSLRL)

  • sacrum is extended → L5 has to be flexed

diagnosis of unilateral extension? unilateral flexion?

• extension:

  • lateralized side → sulci post., ILA ant.

  • other side → opposite

• flexion

  • lateralized side → sulci ant., ILA post.

  • other side → opposite

diagnosis of bilateral extension/flexion?

• (-) seated flexion OR bilateral (+)/equal

• extension → sulci post., ILA ant.

• flexion → sulci ant., ILA post.

during what sacral diagnoses is the sacrum extended?

• backward torsion

• unilateral/bilateral extension

• (+) BBT, (+) spring test

forward sacral torsions MET

• side of oblique axis down on table (lateral recumbent)

• hug the table, down (rotate to side of oblique axis)

• localize sacral base (bend knees + flex hips >90)

• drop pt. leg over table, support w/ your knee (down)

  • pt. lift to ceiling

backward sacral torsion MET

• side of oblique axis down (lateral recumbent)

• pull on lower shoulder, up (rotate to L5)

• localize sacral base (bend knees + flex hips <90)

• drop pt. legs over table, support w/ your knee (down)

  • pt. lift to ceiling

unilateral sacral flexion ME?

• pt. prone, stand on opposite side of flexion

• palpate flexed sacral sulcus → ABduct pt. same leg (loose SI joint) + IR

• heel of caudad hand on ILA w/ cephalad on top → downward force

• pt. inhale → resist, pt. exhale → follow (encourage extension)

unilateral sacral extension?

• pt. in sphinx, stand on opposite side of extension

• caudad hand ABduct pt. same leg (loose SI joint) + IR

• hypothenar on sacral sulcus, stabilize w/ caudad on top

• inhale → resist, exhale → follow (encourage flexion)

bilateral sacral flexion ME?

• place caudad hand on ILA, cephalad reinforce

• inhale → force extension

• exhalation → downward pressure (prevent flexion)

bilateral sacral extension ME?

• pt. prone OR sphinx

• contact sacral sulci w/ caudad hand, cephalad reinforce

• inhale → inc. ant. force/resist

• exhale → encourage flexion/follow

posterior pelvic CS points?

• UPL5 (sup. PSIS) → E Add er/ir

• high ilium sacroiliac (lat. PSIS, press med.) → E Abd ER

• LPL5 (inf. PSIS, press sup.) → F IR Add

• high ilium flare out (lat. ILA or coccyx) → E Add

• PL3/4 lat. (gluteus medius @ PSIS, TFL) → E Abd er

  • 3 → 2/3 lat. PSIS to TFL

  • 4 → post. margin TFL

sacral CS points?

• PS1 bilateral (med. to PSIS @ S1/sacral base) → PA pressure on opp. ILA

• PS2, PS3, PS4 midline (@ level) → F + E

• PS5 (med. + sup. to ILA) → PA pressure on opp. sacral base

what are the typical phases of gait?

• stance (60%): weight shift to R. foot

  • heel strike, foot flat, midstance (bears weight), push (toe) off

• swing phase (40%): R. foot suspended

  • acceleration, midswing, deceleration

what is innominate motion during gait?

• rotation w/ every step

• stance phase (heel strike) → post. rotation

• swing phase (toe off) → ant. rotation

what is sacral motion when Left vs Right leg is weight bearing?

• neutral oblique axis w/ lumbar sidebending towards side of weight bearing leg

• L. leg → L rotation on L oblique axis (L/L)

  • L5 NSLRR

• R. leg → R rotation on R oblique axis

  • L5 NSRRL

what is arm movement during gait?

pendulum → opposite direction of ipsilateral leg

what type of treatment is HVLA?

• high velocity, low amplitude

• direct + passive

• treats joint SD

what is the muscle spindle mechanism of HVLA?

• joint capsule repositioned → stimulate golgi tendon 1b aff. neuron

• synapses w/ inhibitory 1b interneuron → synapse w/ a-motor neuron

• muscle relax → ROM improve

what is the mechanism of action of HVLA?

• restore articular motion

• release entrapped synovial folds

• disrupt periarticular/articular micro-adhesions

• reset aberrant nociceptive/mechanoreceptor activity

• vacuum/cavitation

HVLA indications? dosage?

• articular SD

• joint motion restriction (distinct, firm articular barrier)

• sicker pt. → lower dose

• long-term use discouraged

HVLA relative contraindications?

• apprehension

• acute herniation, radiculopathy, whiplash/sprain

• osteopenia/osteoporosis, spondylolisthesis (bone disease)

• atypical joint facet, hypermobile state

• Hx of inflammatory disorders (RA, SLE, IMD, psoriasis, scleroderma)

• implanted devices

HVLA absolute contraindications?

• upper cervical (advanced RA, DS, dwarfism, chiari malformation)

• fracture/dislocation/spinal or joint instability

• joint fusion (ankylosing spondylosis, klippel-feil)

• vertebrobasilar insufficiency

• acute inflammatory disorders

• malignancy

• myelopathy, cauda equina/spinal pathology

HVLA approach + after?

• approach: diagnose SD w/ firm end feel, localize segment to restrictive barrier, avoid overloading/guarding, release-enhance

• after: reassess tissue texture, asymmetry, ROM, tenderness + intersegmental motion @ joint level

sequence for supine thoracic HVLA?

• prepare tissue

• stand on opp. side of rotation+ pt. top arm ipsilateral to rotation component

• taut thenar eminence over transverse process w/ spinous process in palm

• pt. thoracic area relax on fulcrum + adjust in F/E (or N)

• localize w/ SB (toward/Type2 or away/Type1)

• control over thoracic/head/neck

• take up slack w/ exhalation → short + quick thrust @ end of exhalation

supine direct HVLA Type I neutral SD?

• extend thorax over fulcrum

• SB away from you

• thrust perpendicular to fulcrum

supine direct HVLA for Type II flexed SD?

• extend thorax to localize

• SB towards you (opposite of rotational SD)

• force-vector for thrust directed cephalad

• reassess

supine direct HVLA for Type II extended SD?

• flex thorax

• SB towards you (opposite of SD)

• force-vector for thrust directed caudad

• reassess

crossed-hand prone HVLA for Type II flexed SD?

• pt. prone

• stand on opp. side of rotation

• caudad thenar eminence on post. contralateral transverse process w/ fingers facing sup. (cephalad hand opp. for SB)

• take up SB + AP slack w/ exhalation

• short + quick thrust @ end of exhalation in direction of fingers

  • greater pressure on post. transverse process

crossed-hand prone HVLA for Type I neutral SD?

• pt. prone

• stand on same side of rotation

• caudad thenar eminence inf. to opposite transverse process w/ fingers to head (cephalad hand opp. for SB)

• move hand fingers pointing to take up slack (eminences should be level w/ process now)

• short + quick thrust @ end of exhalation

  • greater pressure on post. transverse process

HVLA L1-L5 Type I Neutral long-lever SD?

• pt. lat. recumbent (rotation side down) w/ DO face pt.

• palpate under segment → flex knee + hip until segment neutral

• pt. drops top leg over side of table until detect motion at segment

• switch palpation hand → cephalad hand through elbow w/ forearm on pec/shoulder

• caudad forearm btwn PSIS + greater trochanter

• pelvis rotated ant. + shoulder/spine rotated post. → take up slack w/ exhalation

• force vector towards spine

HVLA L1-L5 Type II non-Neutral (flexion) long-lever SD?

• pt. lat. recumbent (rotation side down) w/ DO facing pt.

• palpate under segment → extend (push legs/pelvis post.)

• restrict top leg → pt. extend bottom leg → place ankle in popliteal fossa

• switch monitor hands → pull pt. bottom arm forward until rotation felt under segment

• caudad forearm post. to greater trochanter + cephalad hand grasping elbow

• force vector → shoulder caudad + pelvis cephalad

superior pubic shear ME? inferior pubic shear ME?

• sup.: leg off table w/ ischial tuberosity on table + support opp. ASIS→ pt. push up + slight medial

• inf.: flex + ADduct hip, support ipsilateral ischial tuberosity → pt. push knee into your shoulder

pubic compression ME?

• flex hips + knees w/ feet on table

• ABduct knees w/ forearm btwn knees

• pt. ADduct (pull in) against force

• 3-5 sec force, 2 sec relax, 3-5x

• revaluate

pubic gapping ME?

note: end of midterm

• flex hips + knees w/ feet on table

• ABduct knees (~18 inches) → ADduct knees while pt. ABduct against force

• 3-5 sec force, 2 sec relax, 3-5x

• revaluate

anterior cervical anatomical landmarks? posterior?

• ant.:

  • hyoid → C2-C4

  • thyroid cartilage → C4-C5

  • cricoid cartilage → C6

  • suprasternal notch → T2

• post.:

  • bump under inion → C2

  • prominent spinous process → C7

what is the structure of C1 and C2?

• C1 (atlas) → ring shaped, no body or spinous process

• C2 (axis) → anatomically atypical, but functionally typical

  • odontoid process (dens)

major motions of the cervical region? what is the diagnosis?

• OA → flex/extend

  • Dx: SB + rotate opposite (type 1)

    • translate ease → opp. SB

• AA → rotational

  • Dx: only rotation

• C2-C7 → rotation + SB, flex/extend

  • Dx: SB + rotate same (type 2)

    • translate ease → opp. SB

cervical facet orientation? when do facets open?

• facet orientation → BUM (facets open w/ flex)

  • upper facets (C2-C3) → angled near transverse plane

  • lower facets (C4-C7) → angle tangential to transverse + coronal plane

• facets/articular pillars open w/ flexion (forward bending)

  • w/ SB + rotation → contralateral side open

indications of soft tissue? relative contraindications?

• indications: hypertonic muscles, tension in fascia, improving circulation, preparation, abnormal visceral/somatic reflex

• relative CI: fracture/open wound, ST/bony infection, abscess, DVT, coagulopathy, neoplasm, directly over site of recent operation

• absolute → lack of consent

characteristics of soft tissue technique?

• direct/passive

• low amplitude, rhythmic

• mechanisms:

  • deep pressure → sustained inhibitory pressure

  • kneading → rhythmic, lat./perp. stretch

  • traction → sustained linear force, long. separation of myofascial structures

other mechanisms of soft tissue technique?

• effleurage → stroking distal to prox., move fluid

• petrissage → deep kneading/squeezing express fluid

• tapotement → strike muscle belly, inc. tone + perfusion

• skin rolling → myofascial release, break adhesive bands

suboccipital inhibition vs release ST techniques?

• inhibition → bilateral ant. force (to ceiling)

• release → @ C2, ant. force + cephalad traction

cervical supine vs longitudinal traction ST technique?

• supine → cradle occiput + under mandible, f + cephalad traction

• longitudinal → contact cervical paravertebral muscles, ant. force + cephalad traction

cervical longitudinal vs contralateral kneading ST technique?

• longitudinal → contact cervical paravertebral muscles, ant. force + cephalad traction rhythmic

• contralateral → caudad hand contact cervical paraspinal + draw ant. rhythmically, cephalad hand stabilize forehead

cervical forward bending forearm fulcrum bilateral vs unilateral ST technique?

• bilateral (FB) → cross arms under head + palms on shoulders, flex neck

• unilateral (FB, SB, R) → flex head w/ one hand, slide 2nd hand over opp. shoulder, rotate head along forearm to elbow until tension felt

supine lateral traction w/ shoulder cervical ST technique?

• one hand on pt. AC joint on side of treatment

• other hand under occiput from other side→ gently rotate head away from treatment side

  • until tension felt → return to neutral

CS indications + contraindications?

• indications: tender pt., acute injury, SD, hospitalized/frail, hypertonic muscle

• relative CI: can’t relax/tolerate/comm., vert. a. disease, upper cervical (lig., dens, osteoporosis), RA, arthritis, PD

• absolute: lack consent, neurological symptoms, degenerative spondylosis

what are the components of muscle tone?

• intrafusal fibers → muscle length

• GTO → tendon tension

• yMNs → regulate gain of stretch reflex via adjusting intrafusal fibers

  • sets baseline act. in aMNs

pathophysiology of a CS tender point?

• agonist contract → muscle spindle lengthens → CNS inc. y eff. to tighten

• lengthens antagonist → CNS detects dec. spindle firing → inc. y eff. drive → hypersensitive muscle spindle (new normal) + lock in contraction → tender pt.

• treat via passively shorten muscle → spindle aff. fibers dec → y eff. fibers firing dec./reset

tender vs trigger vs chapman treatment?

• tender → CS

• trigger → firm pressure

• chapman → direct inhibition, rotary motion

AC1* tender points treatment?

• mandible or transverse process

• RA

• neck pain, headache (migraine, TMJ)

AC2-6 tender points treatment?

• transverse process

• F Sa Ra

• neck pain, headache

AC7* tender point treatment?

• post. sup. clavicle

• F St Ra

• Flex a STRAw into 7-up

• lower cervical or SCM restriction

AC8 tender point treatment?

• sup. med. clavicle @ sternal attachment to SCM

• f-F Sa Ra

• lower cervical or SCM restriction

PC1 tender point treatment?

• inion* → F St Ra

• occiput → e-E Sa Ra

• post. lat. headache, pain behind eye

PC2 tender point treatment?

• occiput → e-E Sa Ra

• midline spinous process → e-E Sa Ra

• periorbital/temporal headache

PC3-PC8 tender point treatment?

• PC3* midline → f-F Sa Ra

• PC4-PC8 midline (bottom of spinous process above) → e-E Sa Ra

• neck pain + headache

trapezius MET?

• flex neck to barrier

• pt. extend head w/ equal force

oculucephalogyric reflex MET?

• extension → pt. look up, relax, DO extend head to near barrier

• flexion → pt. looks down

• R. SB → look up + right

• L. SB → look up + left

OA, AA, C2-C7 MET?

• OA → contact suboccipital muscle + under chin, engage barriers

• AA → gently flex, rotate into barrier

• C2-C7 → 2nd MCP @ articular pillar of segment being treated, slight flexion → engage barriers

special tests cervical HVLA?

• hoffman’s sign → UMN lesions (myopathy)

  • dorsiflex wrist, extend middle finger + stabilize PIP → flick DIP (+ = flex + adduct thumb/ flex index finger)

• lhermitte sign → cervical myelopathy via cord compression

  • flex head + hip (+ = electric shock down spine)

• spurling’s test → cervical radiculopathy

  • head extended, SB, rotated TOWARD affect side (+ = pain radiating down same arm)

SD end feels? treatment?

• articular → via facet joint w/ muscle guarding (treat w/ HVLA)

• muscular → hypertonicity

  • short restrictor → type 2, intrinsic segmental

  • long restrictor → type 1, int. + deep

• fascial/ligamentous → shortening

• edema-causing → less slack via fascial distension

contraindications HVLA?

• relative: HNP, acute radiculopathy, acute spasm strain, osteopenia/porosis, spondylolisthesis, hypermobility, implants, inflammation Hx

• absolute: down syndrome/RA (AA unstable → transverse lig. of dens rupture), chiari malformation, achondroplastic dwarfism (foramen magnum narrow), joint fusion (ankylosis/spondylosis), fracture, klippel-feil (fusion of 2+ segments), vertebrobasilar insufficiency, acute inflammatory, malignancy, spinal cord pathology

typical cervical vertebrae HVLA (rotational emphasis)?

• contact articular pillar w/ right 2nd MCP, rest thumb on bony facial surface

  • stand on side of rotational ease

• ant. translate pillar → flex until segment → rotate (to barrier) + SB (to ease)

• take up slack as pt. exhales → rotational thrust to barrier

typical cervical vertebrae HVLA (sidebending emphasis)?

• contact articular pillar w/ right 2nd MCP, rest thumb on bony facial surface

  • stand on side of rotational restriction

• ant. translate pillar → flex until segment → SB (to barrier) + rotate (to ease)

• take up slack as pt. exhales → translatory thrust to barrier

OA cervical HVLA?

• contact articular pillar w/ right 2nd MCP, rest thumb on bony facial surface

  • stand on side of rotational ease

• sup. traction + slight ant. pressure (extension)

• rotate head to barrier → then SB into barrier → slight ant. pressure

• rotational thrust

AA cervical HVLA?

• contact articular pillar w/ right 2nd MCP, rest thumb on bony facial surface

  • stand on side of rotational ease

• flex head 45 → slight ant. pressure

• rotate into barrier → take up slack w/ breaths → end of exhale → rotational thrust

which nerve roots commonly cause cervical radiculopathy? tests for cervical radiculopathy vs myelopathy? red flags for cervical pain?

• C6, C7

• radiculopathy (spurling, shoulder abduction, neck distraction, valsalva) vs myelopathy (lhermitte, hoffman, babinski, hyperreflexia, clonus)

• trauma, constitutional symptoms, UMN lesion, age <20 or >50, and concurrent chest pain/diaphoresis, SOB