Term
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Definition
Fascia is a connective issue covering over all surfaces within the body
It envelopes all fibers, muscles, tendons and organs
Fascia is a continuous sheet, not
individual baggies for each organ |
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Term
| which types of tissues may myofascial release be performed on and what does it accomplish? |
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Definition
MFR may be performed on various tissues including fascia, tendons, cicatrices (scars), internal organs, or visceral suspensory ligaments.
MFR decreases myofascial tone at a segmental level in treating spinal somatic dysfunction. |
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Term
| how long is counterstrain held for? |
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Definition
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Term
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Definition
An osteopathic system of diagnosis and indirect treatment in which the patient’s somatic dysfunction, diagnosed by an associated myofascial tenderpoint, is treated by using a position of spontaneous tissue release while simultaneously monitoring the tenderpoint
An indirect technique in which the tissue being treated is positioned at a point of balance, or ease, away from the restrictive barrier
To treat the strain, the physician counters the strain by reintroducing the original strain, which is the position of ease
Counterstrain is based on identifying tender points and positioning the patient to eliminate the tenderness |
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Term
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Definition
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 |
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Term
| what is the indirect method? |
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Definition
A manipulative technique where the restrictive barrier is disengaged
The dysfunctional body part is moved away from the restrictive barrier until tissue tension is equal in one or all planes and directions |
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Term
| release in indirect method is by ______ forces instead of physician forces. |
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Definition
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Term
| describe how to perform facilitated positional release (FPR) on a patient |
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Definition
Patient position: supine
Physician position: seated at the head of the table
Patient moves up the table until his/her neck are off the table and supported by the physician
With the thumb, palm, and middle finger of the left hand, the physician cradles the patient’s neck
Physician’s middle finger is on the tissue to be treated, while the rest of the hand helps support the patient’s neck
The physician gently bends the head and neck forward to flatten the cervical lordosis
From this starting position, the physician gently applies axial compression on the patient’s vertex, with the vector of force directed through the patient’s head towards his/her feet
Less than 1 pound of force is sufficient-just enough to be felt at the physician’s left index finger
Maintaining axial compression, the physician bends the patient’s neck backward, then side bends it up to the physician’s left index finger. This maneuver causes shortening and relaxation of the tissue being treated
This position is held for 3-5 seconds, then released and the area of dysfunction reevaluated |
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Term
| how would a physician perform indirect joint stacking on a patient's phalanx? |
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Definition
Pick any finger on your patient
If in doubt, use the index finger
Find the Interphalangeal joint
Motion test
flexion, extension, rotation, sidebending, traction or compression
Hold in position of ease
You may add respiratory force/cooperation
Recheck |
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Term
| what is jones strain counterstrain (JSC)? |
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Definition
Indirect technique aimed at reducing the gamma gain on a structure (muscle, ligament)
This is a passive treatment, the patient does not help with body positioning!!! |
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Term
| describe how to locate the piriformis tenderpoint |
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Definition
locate the PSIS and the ipsilateral ILA
Determine the halfway point
locate the greater trochanter of the femur and draw a line between it and the midway point found earlier
draw a line between those two points and determine the new midway point -
this is the tenderpoint of the piriformis muscle |
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Term
| how would a physician perform the jones strain-counterstrain piriformis tender point on a patient |
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Definition
locate piriformis tenderpoint
while monitoring tenderpoint with thumb, doc flexes pt’s knee and begins to abduct, flex and externally rotate the hip until pt states that the pain has decreased to ~ 3/10
hold for 90 sec
return leg to normal position SLOWLY without help from patient
reassess |
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Term
| what is the difference between direct and indirect method? |
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Definition
Direct:
the restrictive barrier is engaged and a final activating force is applied to correct somatic dysfunction
Indirect:
the dysfunctional body part is moved away from the restrictive barrier until tissue tension is equal in one or all planes and directions |
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Term
| what is the difference between active and passive method? |
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Definition
Active method:
Technique in which the person voluntarily performs a physician-directed motion
Passive method:
Based on techniques which the patient refrains from voluntary muscle contraction. |
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Term
| what are some indications for use of indirect method? |
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Definition
Indications
Acute painful situations
Trauma
Hospitalized patients
Metastatic cancer
Arthritis
Osteoarthritis, rheumatoid arthritis
Osteoporosis
Limitations of patient positioning for other techniques
Patient’s preference |
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Term
| what are some contraindications for indirect method? |
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Definition
Inability to position patient appropriately
Patient’s preference
Fractures, open wounds |
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Term
| what is an activating force? |
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Definition
Force which is used to correct somatic dysfunction
Intrinsic or extrinsic
Indirect method uses INHERENT FORCES (intrinsic)
Natural tendency of the body to seek homeostasis
Rhythmic activity present in all living tissues |
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Term
| what is respiratory cooperation? |
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Definition
| A physician directed inhalation and/or exhalation by the patient to assist the manipulative process |
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Term
| what is respiratory force? |
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Definition
| The force brought to bear when the patient is instructed to hold their breath in either inhalation or exhalation beyond their usual comfortable limits so that a force will exert itself upon the lesioned structure |
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Term
| what happens to spinal segments during inhalation? |
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Definition
External rotation, spinal curves tend to flatten
muscles tend to tighten |
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Term
| what happens to spinal segments during exhalation? |
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Definition
internal rotation, spinal curves tend to increase
muscles tend to relax |
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Term
| what are some special considerations for myofascial release? |
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Definition
MFR may be performed on various tissues including fascia, tendons, cicatrices (scars), internal organs, or visceral suspensory ligaments.
MFR decreases myofascial tone at a segmental level in treating spinal somatic dysfunction. |
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Term
| how would one perform myofascial release on a patient? |
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Definition
Very gentle yet firm contact
Assess motion in three planes
Guide fascia into direction of ease in all planes
Find point of equal balance
Don’t go to new barrier!
Constantly rebalance
may incorporate respiratory force, cooperation |
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Term
| what are some key points to keep in mind when performing indirect joint guiding/joint stacking? |
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Definition
Assess motion in all planes
Guide joint into direction of ease in all planes
Find point of equal balance
Constantly rebalance
May use respiratory force & allow intrinsic forces to work |
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Term
| what is reciprocal inhibition? |
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Definition
reflex mechanism whereby antagonist muscles are contracted
causing reflex stretch in agonist muscles
Example- when biceps m. contracts, triceps m. relaxes |
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Term
| what are some characteristics/benefits of upright posture? |
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Definition
is “statically” unstable
Human frame resembles three inverted pyramids stacked vertically
Center of gravity is as high as possible
Potential energy is maximized
Easy to change position
Easy to restore |
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Term
| true or false: upright posture allows easy rotation |
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Definition
true
Rotation in the Upright Posture
There is an Axis, a midline
Moment of inertia is small
Humans can turn around themselves or rotate very readily
Teleceptors (the distance senses: Vision and sound, etc) can orient very quickly |
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Term
| what are "transition zones"? |
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Definition
Areas where curves reverse are commonly
susceptible to somatic dysfunction
Location
- Occipito-cervical junction
- Cervico-thoracic junction
- Thoraco-lumbar junction
- Lumbo-sacral junction
Changes include:
- Bony changes to the vertebrae
- Changes in the Sagittal plane
- muscular & fascial changes
Also look at the apex of the curves for dysfunction |
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Term
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Definition
Scoliosis is an appreciable deviation of a group of vertebrae from the normal straight vertical alignment of the spine
The primary onset for scoliosis is 10-15 years old
Scoliosis occurs equally among both genders.
However, females are eight times (800%) more likely to progress to a curve magnitude that requires treatment. |
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Term
| how would one classify scoliosis? |
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Definition
Reversibility
Severity
Cause
Location |
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Term
| what is a functional scoliotic curve? |
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Definition
| Curve reduced with side bending, rotation or forward bending |
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Term
| what is a structural scoliotic curve? |
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Definition
| Curve fixed and not reduced with side bending, rotation or forward bending |
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Term
| what are the degrees of severity for scoliosis? |
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Definition
Mild = 5–15 degrees
Moderate = 20-45 degrees
Severe = greater than 50 degrees
Cobb angle >500 = high probability of requiring surgical correction |
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Term
| what are some causes of scoliosis? |
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Definition
Idiopathic
- No known cause
- 70 – 90% of all scoliotic curves
- Most common
Congenital
- 75% are progressive
- 2nd most common
Acquired
- Short leg syndrome
- Hip prosthesis
- Osteomalicia
- Sciatic irritability
- Psoas syndrome
- Healed leg fracture |
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Term
| what is a scoliometer and what does it measure? |
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Definition
Scoliometer measures the ATR (Angle of Trunk Rotation or Axial Trunk Rotation).
Good correlation between scoliometer reading (ATR) and scoliosis measured using Cobb Method
ATR angle is different than Cobb Angle!
5 degree ATR angle requires radiographic evaluation to determine Cobb Angle (Usually correlates to 10 – 120 Cobb Angle) and follow-up screening in 6 months.
7 degree or greater ATR angle requires referral to a scoliosis specialist (Usually correlates to >200 Cobb Angle)
Scoliometer measurement should be used for screening only. Measurement of Cobb Angle is confirmatory test. |
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Term
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Definition
| Step length= distance between the point of initial contact of one foot & the point of initial contact of the opposite foot. |
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Term
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Definition
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Term
| what is velocity in regards to gait? |
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Definition
| cadence X step length (in units of distance per time) eg: MPH, KPH etc |
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Term
| what is the average width of stride? |
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Definition
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Term
| what is the average length of step? |
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Definition
| heel strike of one foot to heel strike of opposite foot = average 15” |
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Term
| what is the average length of gait cycle (stride)? |
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Definition
| heel strike of one foot to heel strike of same foot = average 30” |
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Term
| describe the stance and swing phase during gait |
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Definition
Stance phase = heel strike to toe off = 60% of Gait Cycle = foot in contact with ground at all times
Swing phase = toe off to heel strike = 40% of Gait Cycle = foot does not contact ground at any time |
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Term
| describe the stance phase of gait |
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Definition
Heel Strike (HS) The heel of the loading extremity “strikes” the ground
Foot Flat (FF) The foot fully contacts the ground
Midstance (MST) body weight passes directly over the supporting extremity
Heel off (HO) heel leaves the ground
Toe off (TO) Only toe remains on ground |
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Term
| describe the swing phase of gait |
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Definition
Acceleration (Acc) - from toe off until midswing
Midswing (MSW) – extremity directly below torso
Deceleration (Dec) – from midswing to heel strike |
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Term
| what is the difference between walking and running? |
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Definition
Walking = Heel strike of one foot briefly overlaps the toe off of the opposite foot = a brief period of both feet in contact with ground
Running = no double stance phase and there is a period when both feet are off of the ground
- Running is therefore literally jumping or bounding or “flying” |
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Term
| true or false: the center of gravity moves slightly higher and lower in phases of the gait cycle |
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Definition
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Term
| what are the determinants of gait? |
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Definition
Pelvis, knee & ankle are all active participants in gait.
Pelvic rotation and pelvic tilt are present
Knee flexion & extension
Ankle dorsi-flexion & plantar flexion |
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Term
| how much does the pelvis typically rotate during gait? |
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Definition
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Term
| by how much does the pelvis and trunk laterally displace during gait? |
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Definition
| 2 cm (1") to weight-bearing side |
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Term
| when is the pre-tibial muscle group most active in gait? |
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Definition
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Term
| when is the quadriceps muscle group most active in gait? |
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Definition
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Term
| what are some neurologic gaits? |
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Definition
Hemiplegic Gait
- “Extensor Synergies”
- Hip extension & Internal rotation
- Knee extension
- Plantar Flexion & foot inversion
Spastic Diplegia
- Affects “only” the lower extremities
- Knee extended
Compass” Gait = Bipedal gait with movement only at the hip and ankle
Antalgic Gait– “counteracting or avoiding pain” - Limp
Parkinsonian Gait
- Small steps, shuffling gait (Festinating Gait)
- Stooped posture |
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Term
| what is a pathologic gait? |
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Definition
Gait with weak dorsiflexors of the foot such as L5 Radiculopathy or peroneal neuropathy
- Circumduction of the swing leg
- Hip hiking of the swing leg
- Swing leg lifted abnormally high (steppage gait)
- Seen in motor neuron disease such as polio and in peripheral neuropathy
Vaulting on the stance leg |
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Term
| how should one use a cane? |
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Definition
Cane should rest on the ground with your hand on it and your elbow slightly bent when you are standing up straight.
A cane should normally be carried in the opposite hand from your injured leg.
While injured leg and is in swing phase, move the cane forward at the same time.
Then, bearing your weight partly on the cane and partly on your injured leg, you will swing the good leg through and take another normal step with it. |
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Term
| describe the proper usage of crutches |
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Definition
Crutches placed anteriorly
Patient swings his/her legs forward to crutches
Going down stairs- crutches placed on lower step & legs brought level to crutches
Going up stairs- crutches remain on the lower step as good leg is raised to upper step- crutches follow
Single crutch- use same as a cane |
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Term
| how should one fit crutches? |
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Definition
Adjust length so crutches are 5cm below axilla
Adjust handles so thenar & hypothenar areas can take full weight while elbow is straight
Crutches must always have rubber tips |
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Term
| describe soft tissue direct technique |
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Definition
Directed at tissues other than skeletal or arthrodial
Usually involves lateral / linear stretching, and/or deep pressure, traction and/or separation of muscle origin & insertion while monitoring tissue response & motion changes by palpation.
Therapeutic goal: muscular & fascial relaxation
Soft tissue technique is a direct technique that usually involves lateral stretching, linear stretching, deep pressure, traction and/or separation of muscle origin and insertion while monitoring tissue response and muscle changes by palpation. |
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Term
| what are the proposed mechanisms for soft tissue technique? |
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Definition
Relaxes hypertonic muscles and reduce spasm
Stretches and increases the elasticity of shortened fascial structures
Enhances circulation to local myofascial structures
Improves local tissue nutrition, oxygenation, and removal of metabolic wastes
Improves abnormal somato-somatic and somato-visceral reflex activity, thus improving circulation in areas of the body remote from the area being treated
Identifies areas of restricted motion, tissue texture changes and sensitivity
Improves local and systemic immune response
Provides a general state of relaxation
Provides a general state of tonic stimulation by stimulating the stretch reflex in hypotonic muscles |
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Term
| what are some indications for soft tissue technique? |
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Definition
Somatic dysfunction of the soft tissues of the body as characterized or inferred by asymmetry, restriction of motion, tissue texture changes and tissue tenderness:
hypertonic muscles
excessive tension in fascial structures
abnormal somato-somatic and somato-visceral reflexes
Clinical conditions that would benefit from:
enhanced circulation to local myofascial structures
improved local tissue nutrition, oxygenation, and removal of metabolic wastes
improved local and systemic immune responsiveness
As an adjunct to additional manipulative treatment in order to:
identify other areas of somatic dysfunction
observe tissue response to the application of manipulative technique
provide a general state of relaxation
provide a general state of tonic stimulation
prepare tissues for other types of manipulation |
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Term
| what are some contraindications for soft tissue technique? |
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Definition
Absence of somatic dysfunction
Lack of patient consent and/or cooperation
Skin: Disorders which would preclude skin contact, e.g., contagious skin diseases, acute burns, painful rashes, abscesses, skin cancers, etc.
Fascia: Acute fasciitis (infectious or autoimmune), acute fascial tears
Muscle: Acute muscular strains, acute myositis, muscle neoplasms.
Ligament: Acute ligamentous sprain, acute ligamentous inflammatory disorders, septic arthritis, primary or secondary joint neoplasms.
Bone: Acute fracture, osteomyelitis, primary or secondary bone tumors, osteoporosis
Viscera: Infectious or neoplastic enlargement of organs such as the liver and spleen. Gastric or bowel obstruction or distention. Acute organ pain, e.g., pyelonephritis. Undiagnosed abdominal or pelvic pain.
Vascular: Hematoma, deep venous thrombosis, uncontrolled bleeding disorders |
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Term
| what are the principles of treatment for soft tissue technique? |
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Definition
Soft tissue technique is a passive direct technique.
There are three basic mechanisms used in applying soft tissue technique.
1. Tractional technique, also called stretching, in which the origin and insertion of the myofascial structures being treated are longitudinally separated.
2. Kneading, a rhythmic, lateral stretching of a myofascial structure, in which origin and insertion are held stationary and the central portion of the structure is stretched like a bowstring.
3. Inhibition, sustained deep pressure over a hypertonic myofascial structure.
Other mechanisms used on more superficial fascial structures include variants on techniques developed in the European massage movement:
Effleurage
Petrissage
Tapotement
Skin Rolling |
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Term
| what is myofascial release? |
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Definition
| Myofascial release (MFR) is a system of diagnosis and treatment, first described by Andrew Taylor Still and his early students, which engages continual palpatory feedback to achieve release of myofascial tissues. |
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Term
| compare and contrast direct and indirect myofascial release |
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Definition
Direct MFR, a myofascial tissue restrictive barrier is engaged for the myofascial tissues and the tissue is loaded with a constant force until tissue release occurs.
Indirect MFR, the dysfunctional tissues are guided along the path of least resistance until free movement is achieved. |
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Term
| what are the proposed mechanisms for myofascial release? |
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Definition
Fascia is capable of changes in length (plasticity and elasticity), with associated changes of energy content (hysteresis).
MFR provides peripheral neuroreflexive alterations in muscle tone and neural facilitation, in part, by its influence on mechanoreceptors.
The application of MFR allows for connective tissue plastic changes (creep) which are associated with release of energy. This may include heat, electromagnetic, and piezoelectric changes.
External forces applied to fascia facilitate restoration of normal structure and function.
Tensegrity principles coupled with fascial bioelectric (piezoelectric) properties influence the anatomical and physiological responses of tissues to applied manipulative forces. |
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Term
| how would a physician go about diagnosing the anterior/posterior radial head? |
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Definition
With thumb and index finger grasp radial head- monitor for reciprocal motion at end of pronation & supination
Diagnosis
Symptoms: Elbow discomfort with inability to fully supinate the forearm
Motion: Restricted supination of the forearm Palpation: Tenderness at the radial head with posterior prominence of the radial head |
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Term
| describe the still technique for radial head, pronation dysfunction |
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Definition
The patient is seated on the table, and the physician stands in front of the patient.
The physician holds the patient's hand on the dysfunctional arm as if shaking hands with the patient.
The physician places the index finger pad and thumb of the other hand so that the thumb is anterior and the index finger pad is posterior to the radial head.
The physician rotates the hand into the indirect pronation position and pushes the radial head posteriorly with the thumb until the ease barrier is engaged.
Finally, the physician, with a moderate acceleration through an arclike path of least resistance, supinates the forearm toward the restrictive bind barrier and adds an anterior directed counterforce with the index finger pad.
The release may occur before the barrier is met. If not, the radial head must not be carried more than a few degrees beyond.
The physician reevaluates the dysfunctional (TART) components. |
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Term
| what are the symptoms for a patient with radial head, supination dysfunction? |
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Definition
Symptoms: Elbow discomfort with inability to fully pronate the forearm
Motion: Restricted pronation of the forearm Palpation: Tenderness at the radial head with anterior (ventral) prominence of the radial head |
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Term
| describe the still technique for radial head, supination dysfunction |
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Definition
The patient is seated on the table, and the physician stands in front of the patient.
The physician holds the patient's hand on the dysfunctional arm as if shaking hands with the patient.
The physician places the index finger pad and thumb of the other hand so that the thumb is anterior and the index finger pad is posterior to the radial head
The physician rotates the hand into the indirect supination position and pushes the radial head anteriorly with the index finger pad until the ease barrier is engaged.
Finally, the physician, with moderate acceleration through an arclike path of least resistance, pronates the forearm toward the restrictive bind barrier and adds a posterior directed counterforce with the thumb.
The release may occur before the barrier is met. If not, the radial head must not be carried more than a few degrees beyond.
The physician reevaluates the dysfunctional (TART) components. |
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Term
| how would a physician perform HVLA on the right radial head posterior? |
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Definition
patient sits and the physician stand in front of the patient
physician applies a hand shake grip on the side of the patient's dysfunction and places his/her index finger on the patient's radius
the physician applies anterior pressure against the posterior aspect against the posterior aspect of the radial head with the thumb of his/her other hand
physician extends the elbow to within several degrees of full extension and supinates the hand to the restrictive barrier
a high velocity, low amplitude thrust is applied anteriorly to the radial head as the forearm is supinated
recheck |
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Term
| how would a physician perform HVLA on the right radial head anterior? |
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Definition
patient sits and the physician stands facing the patient
physician grasps the patients distal forearm with the hand opposite the dysfunction and pronates the forearm
physician places the hypothenar eminence of his/her other hand over the radial head
physician flexes the elbow over the fulcrum to create a posterior force on the radial head
a high velocity, low amplitude thrust is applied by increasing flexion and pronation
recheck |
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Term
| how would a physician diagnose ulnar somatic dysfunction in adduction/abduction? |
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Definition
Dr. contacts patient’s elbow and wrist at elbow - thenar eminence to medial aspect of olecranon and finger to lateral condyle
Apply force laterally with the thenar eminence and medially with your fingers
If the proximal ulna moves laterally
Lateral glide with Adduction S/D
If the proximal ulna moves medially
Medial glide with Abduction S/D |
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Term
| what is opponen's roll and how is it performed? |
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Definition
Grasp first digit (thenar emin.) and fifth digit (hypothenar emin.) with each hand
Contact pisiform and scaphoid bones with thumbs
Extend wrist, abduct and laterally rotate first digit with counterforce over hypothenar area
Use thumbs to stretch at boney contact points the transverse carpal ligament in lateral/medial direction
Provide stretch to transverse carpal ligament for 3-5 minutes
Perform at each clinic visit and teach patient to perform technique at home on daily basis |
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Term
| what is the squeeze with rapid circumduction technique? |
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Definition
Place heel of both hands over radiocarpal region of carpal bones & interlace fingers
Attempt to distract fingers while squeezing fingers together
Causes the heel of each hand to squeeze together
Circumduct wrist in circular or figure eight fashion
Care should be taken to maintain capsular tension throughout the articulatory sweep
Perform at each clinic visit |
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Term
| how would a physician perform wrist & interosseous membrane ligamentous articular strain? |
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Definition
Grasp the patients hypothenar eminence and thumb as shown in the picture
Supinate the forearm
Flex the wrist
Apply a compressive force downward through the thumb and a distractive force through the hypothenar eminence
While maintaining all of these forces, slowly rotate the hand & forearm into pronation.
If a barrier is encountered, remain there until it releases, then continue in the direction shown
Once the forearm is in complete pronation, carry the wrist into ulnar deviation.
Perform at each clinic visit |
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Term
| describe the embryology of the upper extremities in general |
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Definition
Limb buds develop during 5th week
The bud begins with the activation of mesenchyme in the lateral mesoderm which is covered by a thick layer of ectoderm.
As long bones form, myoblasts aggregate and form large muscle masses usually segmented into Dorsal (Extensors) and Ventral (Flexors)
Motor axons arise from spinal cord and enter bud at 5 weeks
Sensory nerves follow motor |
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Term
| the bony framework of the shoulder consists of what structures? |
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Definition
The clavicle and scapula, which comprise the pectoral girdle
The proximal end of the humerus |
|
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Term
| what are the 3 joints of the shoulder complex? |
|
Definition
Glenohumeral – ball and socket between
Sternoclavicular - saddle
Acromioclavicular - planar
Scapulothoracic (functional joint) |
|
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Term
| describe the glenohumeral joint |
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Definition
Synovial ball and socket joint between the head of the humerus and the glenoid fossa of the scapula allowing greater mobility than any other joint
The articular surface of the humeral head is approximately 2/3 larger than the glenoid
The joint is held together by the tonic activity of the rotator cuff muscles, the fibrocartilage extension of the glenoid (glenoid labrum), joint capsule and reinforcing ligaments.
Movements include:
flexion – extension
abduction – adduction
medial – lateral rotation
circumduction |
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Term
| where is the subacromial bursa located and what is its function? |
|
Definition
Subacromial bursa (Subdeltoid)
Located deep to the deltoid, acromion, coracoacromial ligament and superficial to the supraspinatus tendon
Reduces friction between the supraspinatus tendon and the coracoacromial arch (acromion, coracoacromial ligament, tip of coracoid process) |
|
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Term
| describe the sternoclavicular joint |
|
Definition
Connects the upper limb to the axial skeleton
Saddle Joint with an intra-articular disc
Elevation, depression, protraction , retraction, & circumduction are permitted
The fibrous joint capsule is reinforced by:
anterior & posterior sternoclavicular ligaments
Interclavicular ligaments
costoclavicular ligaments |
|
|
Term
| describe the acromioclavicular joint |
|
Definition
The acromioclavicular joint contains a small articular disk that partially subdivides the articular space
It is a synovial plane joint that allows gliding motion, which occurs when the scapula rotates upward and outward |
|
|
Term
| describe the scapulothoracic joint |
|
Definition
The scapulothoracic joint is a “functional joint” in which the anterior concave surface of the scapula articulates with the convex posterolateral thoracic cage.
It is not a true anatomical joint.
Also called scapulocostal joint
The scapula serves as a mobile platform from which the upper limb operates
Made up of the body of the scapula and the muscles covering the posterior chest wall
Allows the scapula to glide medially, laterally, superiorly and inferiorly and rotate over the posterolateral chest cage
Asymmetry of position usually indicates asymmetry of motion
In the resting position, scapula lies between the 2nd and 7th ribs |
|
|
Term
| describe the range of motion of the shoulder |
|
Definition
Phase I: 0-90°
Supraspinatus starts abduction of humerus and joined by deltoid
At 90° humerus externally rotates because greater trochanter is at top of suprahumeral joint
Phase II: 90-150°
Trapezius pulls from sup. lat. position on scapula & serratus anterior pulls medial and ant from medial border of scapula → 30° scapular rotation about A/P axis to elevate glenoid fossa & clavicle 30°
Phase III: 150-180°
Erector spinae muscle on opposite side contract for extra 30° shoulder abduction
First 120 abduction is GH joint, next 60 is scapulothoracic joint.
For every 2 degrees GH motion, there is 1 degree of Scapulothoracic motion (2:1 ratio). |
|
|
Term
| where do the lymphatics of the upper extremities drain? |
|
Definition
drain to the lateral axillary nodes which drain to the central axillary nodes, then to the apical axillary nodes, to the subclavian lymphatic trunk
the right subclavian ultimately drains in the right lymphatic duct and the left subclavian ultimately drains into the thoracic duct |
|
|
Term
| where d the lymphatics from the anterior thoracic wall and breast drain? |
|
Definition
| pectoral axillary nodes --> central axillary nodes --> apical axillary nodes --> subclavian lymphatic trunk |
|
|
Term
| where do lymphatics from the posterior thoracic wall drain? |
|
Definition
| subscapular axillary nodes --> central axillary nodes --> apical axillary nodes --> subclavian lymphatic trunk |
|
|
Term
| how would a physician inspect the shoulder region? |
|
Definition
Systematically shift your vision throughout those areas that make up the shoulder, starting medially at the manubrium, and proceed laterally. Need to check anterior and posterior aspects.
Look for unusual areas of soft tissue or bony swelling, protrusions, inflammation.
Check for atrophy, joint alignment, scars etc.
Patients must be sufficiently undressed to have appropriate visual access.
Observe pt. walk around the exam room.
Check for symmetry.
Watch for arm swing.
Look for holding arm in unusual or abnormal position. |
|
|
Term
| how should a physician observe the shoulder region? |
|
Definition
As pt. enters exam room, observe body language, arm swings, guarding, etc.
Check shoulder heights, followed by iliac crest heights, and leg length eval. as necessary.
From behind, look for scapular asymmetry. |
|
|
Term
| describe the shoulder's range of motion at the glenohumeral and scapulothoracic joint |
|
Definition
abduction-180 deg
adduction-30-45 deg
flexion-90 deg
extension-45-50 deg
internal rotation-55 deg
external rotation-40-45 deg |
|
|
Term
| what is apley's scratch test? |
|
Definition
Apley’s scratch test (upper: lowest vertebra reached with middle finger, lower: highest vertebra reached with thumb)
It should be noted that most people have inequality in this test as one shoulder is usually tighter than the other (especially in athletes). |
|
|
Term
| what is rotator cuff-impingement syndrome? |
|
Definition
Scarring and thickening of the musculotendinous unit, and surrounding tissue decreases the distance between the cuff and the overlying coracoacromial arch.
The rotator cuff tendons and the subacromial bursa get compressed between the greater tubercle of the humeral head and the lateral edge of the acromion process.
Tenderness at the tip of the acromion
Pain and crepitus may be noted when motions of the arm squeeze and pinch these tissues between the humerus and the overlying arch.
Pt’s often experience lateral shoulder pain, particularly with overhead reaching.
Chronic impingement may lead to subacromial bursal inflammation, chronic rotator cuff tendonitis, and left untreated with degenerative thinning of or rupture of the rotator cuff tendons.
Inflammation of the Suprahumeral “joint”
Often involves chronic irritation of the subacromial bursa |
|
|
Term
| what is the neer impingement test? |
|
Definition
Examiner stabilizes pt’s. shoulder on top, and then passively forward flexes the arm above shoulder level to a fully flexed position.
Pos. test-Pain provoked
Rotator cuff impingement pathology. |
|
|
Term
| what is the hawkin's test? |
|
Definition
Examiner passively rotates humerus into IR while forward flexing to 90 degrees in sagittal plane.
Positive test: Pain produced.
Indicates: Rotator cuff impingement pathology |
|
|
Term
| rotator cuff tears most typically involve which muscle? |
|
Definition
supraspinatus
Patient has difficulty abducting or flexing the arm overhead and the movement is usually accompanied by pain. |
|
|
Term
| what is the drop arm test? |
|
Definition
test-Pt. cannot hold arm out to the side (suggests complete RCT or nerve lesion, esp. C5 )
Rotator Cuff Tear (probable full thickness tear) Begin with arms overhead, hands back-to-back. Ask pt. to slowly lower arms to 90 degrees of vertical ABduction and hold it.
Drop arm positive or extreme weakness with full/empty can: Probable full thickness RCT. Get MRI and ortho consult.
Drop arm negative with mild to moderate weakness full/empty can test:
-RC strain/tendinitis (most likely when no hx trauma)
-Biceps tendinitis/subacromial bursitis
-Adhesive capsulitis
-GH dislocation
-Fractures |
|
|
Term
| what is adhesive capsulitis (frozen shoulder)? |
|
Definition
Insidious onset of stiff, painful shoulder with or without inciting injury
Significantly decreased GH ROM - Active and Passive
External Rotation up to 50%
Internal Rotation (unable to touch thumb to belt)
Abduction less than 90 degrees
Less than 135 degrees of flexion
Inflammation
Fibrous changes in periarticular soft tissue
Decreased joint volume - confirmed by arthography |
|
|
Term
| what are some factors that would predispose an individual to frozen shoulder? |
|
Definition
Immobility
Trauma, CVA, etc.
40-60 yrs. Of age
Female
Diabetes (up to 10 times more prevalent than non-DM)
Thyroid disease
Humeral lesions, eg. OA
Personality disorder
Autoimmune disease |
|
|
Term
| describe the stages of adhesive capsulitis |
|
Definition
Stage 1
Duration of symptoms: 0-3 months
Pain with active and passive ROM
Mild limitation of forward flexion, abduction, internal rotation, external rotation
Exam with patient under anesthesia: normal or minimal loss of ROM
Arthroscopy: erythematous, fibrinous pannus over the synovium. Articular cartilage is WNL.
Pathologic changes: hypertrophic, hypervascular synovitis, rare inflammatory cell infiltrates, normal underlying capsule
Stage 2: “Freezing Stage”
Duration of symptoms: 3-9 months
Pain with active and passive ROM
Significant limitation of forward flexion, abduction, internal rotation, external rotation
Exam with patient under anesthesia: ROM essentially identical to ROM when patient is awake
Arthroscopy: Synovium red, thickened, and inflamed. Adhesions across the dependent fold.
Pathologic changes: hypertrophic, hypervascular synovitis with perivascular and subsynovial scar, fibroplasia and scar formation in the underlying capsule.
Stage 3: “Frozen Stage”
Duration of symptoms: 9-15 months
Minimal pain except at end ROM
Significant limitation of ROM with rigid “end feel”
Exam with patient under anesthesia: ROM identical to ROM when patient is awake
Arthroscopy: Transition from inflammatory synovitis to chronic fibrosis and diminished capsular volume
Pathologic changes: “burned out” synovitis without significant hypertrophy or hypervascularity. Underlying capsule shows dense scar formation.
Stage 4: “Thawing Phase”
Duration of symptoms: 15-24 months
Minimal pain, shoulder motion severely limited at first
No longer synovitis and dependent fold is severely contracted
Slow, progressive improvement of ROM
Examination under anesthesia: data not available |
|
|
Term
| what are some treatment options for frozen shoulder? |
|
Definition
Osteopathic Manipulative Treatment
Benign neglect-Some believe it will resolve itself over 1-2 yrs.
Physical therapy-Cornerstone of treatment (controlled tearing of adhesions/progressive ROM)
NSAIDS, analgesics, heat
Intra-articular corticosteroid injections-Little evidence of efficacy. Pain relief aids PT/OMT.
Closed manipulations (MUA)
Arthroscopic capsular release |
|
|
Term
| what causes winging of the scapula? |
|
Definition
Long thoracic nerve injury
Plegia (or paresis) of the serratus anterior muscle |
|
|
Term
| what is erb-duchenne's palsy? |
|
Definition
Associated with birth trauma
Injury to the upper part of the cord, at the root level of C5 and C6
Paralysis of deltoid, external rotators, biceps, brachioradialis and supinator |
|
|
Term
| what does spurling's test check for? |
|
Definition
| disc and or neurological issues |
|
|
Term
| what does adson's test evaluate? |
|
Definition
| vascular compromise originating in the neck area (either scalene muscle compression or a cervical rib) |
|
|
Term
|
Definition
The examiner extends the patient’s neck and rotates/SBs it to one side with axial compression (caudad)on the pt’s head.
Positive sign: pain elicited down the ipsilateral arm from the neck (the side of the pt.’s symptoms).
Indicates: cervical disc disease/nerve root irritation (Note: pain on ipsilateral side of neck could suggest facet pathology.)
PITFALL: Misinterpreting pain in neck only as + test |
|
|
Term
|
Definition
Neck extended turned toward affected side
Narrows the interscalene space
Modified version - turn head to opposite side
For cervical rib |
|
|
Term
| what is the cross arm test? |
|
Definition
Examiner passively adducts pt’s. arm across the chest wall toward the opposite shoulder with the humerus parallel to the floor.
Positive sign: Pain in AC joint at end range.
Indicates: AC joint pathology.
Note: Do not have pt. elevate elbow as in photo, as this suggests labral pathology.
PITFALL: Not directing elbow toward opposite AC joint |
|
|
Term
| what causes a separated shoulder? |
|
Definition
A fall on the acromion can tear the acromioclavicular ligament.
If the coracoclavicular ligaments tear as well then there is an “AC separation” sometimes referred to as “a separated shoulder”
The scapula separates from the clavicle and falls because of the weight of the upper limb |
|
|
Term
| describe the acromioclavicular and coracoclavicular ligaments |
|
Definition
Acromioclavicular ligament itself is weak and easily injured by a direct blow (either by falling directly on the shoulder or on the outstretched limb/elbow
The coracoclavicular ligament is strong. When the coracoclavicular ligament is torn along with the acromioclavicular ligament, the scapula separates from the clavicle and falls because of the weight of the upper limb. |
|
|
Term
| what is biceps tendonitis? |
|
Definition
Pain is located at the anterior aspect of the shoulder, radiating down into the biceps muscle.
The is pain over the long head of the biceps tendon in the bicipital grove.
The tendon becomes prominent when the humerus is externally rotated. |
|
|
Term
|
Definition
| Examiner externally rotates pt’s arm against resistance. +: Tendon will pop out of groove or pain, indicating unstable biceps tendon or subluxation |
|
|
Term
|
Definition
| Pt. elevates arm against resistance. +: Pain in bicipital groove, indicating tendon pathology, usually tendinitis. |
|
|
Term
| what is an apprehension sign? |
|
Definition
Apprehension Sign Pt. is sitting or in supine position, with the arm vertically abducted to 90 degrees & elbow flexed to 90 degrees. The forearm is then forced into ER past 90 degrees. Can add anterior pressure on posterior glenohumeral joint.
Positive Test: Pt becomes very apprehensive fearing a repeat dislocation. Indicates: GH instability, previous GH dislocation/subluxation. |
|
|
Term
|
Definition
Pt’s. elbow is grasped and inferior traction applied.
Positive test: An indentation appears in the area beneath the acromion.
Indicates: Inferior instability, multidirectional instability |
|
|
Term
| what is thoracic outlet syndrome? |
|
Definition
Entrapment between the Scalenus anterior and medius (1.)
Entrapment between the clavicles and the first rib (2.)
Entrapment between tendon of Pectoralis minor and ribs (3.)
Cervical ribs
Fascial distortions
Thoracic outlet is aggravated by activities that involve elevating arm.
Unlike rotator cuff disorders, the symptoms are often aching in nature and radiate into the distal arm, along the ulnar border of the forearm.
There is often associated pallor, coldness, or numbness of the fingers. |
|
|
Term
| what test is used to assess costoclavicular syndrome? |
|
Definition
halstead or military test
Assessment
Compression of neurovascular bundle between the clavicle and the first rib |
|
|
Term
| wright's test is used to assess what condition? |
|
Definition
hyperabduction syndrome
Assessment
Compression of neurovascular bundle between pectoralis minor muscle and thoracic cage |
|
|
Term
| where is the supraspinatus tender point located? |
|
Definition
| The tender point lies at the mid supraspinatus muscle just superior to the spine of the scapula |
|
|
Term
| where is the infraspinatus tender point located? |
|
Definition
| The tender point lies approximately 1 thumb's-width medial to its tendinous portion at the lateral shoulder joint insertion and 1 or 2 thumb's-widths below the spine of the scapula (inferolateral spine of scapula at posteromedial aspect of glenohumeral joint). Others may present along the inferior spine of the scapula to vertebral border of the scapula. These may necessitate placing the patient's arm in more or less flexed or abducted positions. |
|
|
Term
| where is the levator scapulae tender point located? |
|
Definition
| The tender point lies at the superior angle of the scapula |
|
|
Term
| where do the flexors of the forearm attach and what nerve innervates them? |
|
Definition
Attach to medial epicondyle
Mostly median nerve |
|
|
Term
| where do the extensors of the forearm attach and what nerve innervates them? |
|
Definition
Attach to lateral epicondyle
All radial nerve |
|
|
Term
| what is the interosseous membrane? |
|
Definition
Fibers extend cephalad from attachment on ulna to attach proximally on radius
Functionally links true elbow & wrist joints
Allows sharing of compressive forces & movements |
|
|
Term
| describe the differences between supination and pronation in regards to location of the radial head and the interosseous membrane |
|
Definition
Supination
Distal radius moves posterior & lateral
Radial head glides anterior
Interosseous membrane becomes taut
Pronation
Distal radius crosses over ulna
Moves anterior & medial
Radial head glides posterior
Interosseous membrane becomes loose |
|
|
Term
| what is the parallelogram effect? |
|
Definition
As ulna abducts, radius glides distally & wrist is pushed into increased adduction
As ulna adducts, radius glides proximally and wrist is pulled into abducted position |
|
|
Term
|
Definition
Common problem
Overuse syndromes associated with any activity that requires repetitive pronation/supination and associated wrist flexion/extension
Lateral epicondylitis- “Tennis elbow”
Medial epicondylitis- “Golfer’s elbow” |
|
|
Term
| describe lateral epicondylitis |
|
Definition
Strain of the extensor muscles near the lateral epicondyle
Repetitive strenuous supination, or by violent extension with the forearm pronated
Wrist extensors involved
Pain is noticed on lateral aspect of elbow and can radiate down the posterior forearm and into the dorsum of hand
Pain is felt during grasping and lifting-movements that involve extension of the wrist or where the wrist extensors act to stabilize the joint |
|
|
Term
| describe medial epicondylitis |
|
Definition
Strain of the flexor muscles near the medial epicondyle
Repetitive strenous pronation, or by violent flexion with the forearm supinated
Wrist flexors involved
Aggravated by flexion of the wrist against resistance
Involves flexion or stabilization of the wrist by the wrist flexors |
|
|
Term
| what is the most common articular somatic dysfunction found in the elbow? |
|
Definition
radial head somatic dysfunction
Can often mimic the symptoms of tennis elbow and may at times occur simultaneously with tennis elbow |
|
|
Term
| which way does the radial head glide during supination? |
|
Definition
anteriorly
An anterior radial head may result from a fall backward on an outstretched arm |
|
|
Term
| which way does the radial head glide during pronation? |
|
Definition
posteriorly
A posterior radial head may result from a fall forward on an outstretched arm |
|
|
Term
| somatic dysfunction of the anterior radial head causes restricted motion where? |
|
Definition
posterior and pronation
caused from falling backward on outstretched arm |
|
|
Term
| somatic dysfunction of the posterior radial head causes restricted motion where? |
|
Definition
anterior and supination
caused by falling forward on outstretched arm |
|
|
Term
| true or false: an abducted ulna is more common than a adducted ulna |
|
Definition
true
Named for distal aspect of the ulna with respect to the body
Abducted ulna is more common than adducted ulna
Increased carrying angle with abducted ulna
Decreased carrying angle with adducted ulna
When there is restriction of abduction/adduction, the flexion/extension range of the elbow is diminished
Additionally, you may find an abducted ulna in patients with wrist problems or an entrapped ulnar nerve |
|
|
Term
| what are the 3 functional joints of the wrist and what 2 planes does the wrist move in? |
|
Definition
The wrist contains three functional joints
True wrist joint (Radiocarpal)
Midcarpal joint-exists between the two rows of carpal bones
Distal radioulnar joint
The wrist moves in two planes
Sagittal plane (flexion/extension)
Coronal plane (abduction/adduction)
Pronation and supination occur at the radioulnar joint and when combined with the other motions of the wrist, permits circumduction of the hand |
|
|
Term
| describe the 3 different sections of muscles of the hand and which nerve innervates each |
|
Definition
Muscles of thenar eminence
Innervated by the median nerve except for adductor pollicis brevis (ulnar nerve)
Muscles of the hypothenar eminence
Innervated by the ulnar nerve
Lumbricles and interosseous
Ulnar = interosseous, 3rd and 4th lumbricles
Median = 1st and 2nd lumbricles |
|
|
Term
| what are the intrinsic thenar muscles and what are they innervated by? |
|
Definition
These are:
-Abductor pollicis
brevis
-Opponens pollicis
-Flexor pollicis
brevis
All are innervated by the recurrent branch of the median nerve
Variations exist & important in diagnosis |
|
|
Term
| the PAD muscles are innervated by which nerve? |
|
Definition
| deep branch of the ulnar nerve |
|
|
Term
| what are the lumbrical muscles? |
|
Definition
These muscles flex the digits at the metacarpophalngeal (MCP) joints
The 1st 2nd are innervated by the median nerve
The remaining 2 are innervated by the deep branch of the ulnar nerve
Flex the metacarpophalangeal (MP) joints |
|
|
Term
| what are the boundaries and contents of the carpal tunnel? |
|
Definition
Posterior Border
Carpal bones
Anterior Border
Transverse carpal ligament/flexor retinaculum
Boundaries
Proximally – pisiform and tubercle of navicular
Distally – hook of hamate and tubercle of trapezium
Contents
Flexor digitorum superficialis
Flexor digitorum profundus
Flexor pollicis longus
Median nerve |
|
|
Term
| what is carpal tunnel syndrome? |
|
Definition
Compression of median nerve in carpal tunnel
Anesthesia
Paresthesia
Pain
Muscle weakness
Numerous etiologies
Hypothyroidism
Pregnancy
Diabetes
Etc.
When evaluating a patient with carpal tunnel syndrome it is necessary to examine four distinct areas for somatic dysfunction
Carpal tunnel
Upper extremity (especially the forearm)
Brachial plexus (include as leaves the spinal cord)
Upper thoracics |
|
|
Term
| sympathetic innervation to the upper extremities is from which spinal units? |
|
Definition
T2-T8
anterior to the rib heads |
|
|
Term
| where will tenderness occur with a scaphoid fracture? |
|
Definition
May occur from a fall on an outstretched arm
Tenderness will be present in the anatomic snuffbox
May not show up immediately on X-ray
Can be difficult to treat conservatively due to the bone’s retrograde blood supply that can be compromised with the fracture
Loss of blood to the proximal aspect of the bone can lead to avascular necrosis and non-union at the fracture site |
|
|
Term
|
Definition
| wrist flexion to maximum for 60 seconds |
|
|
Term
|
Definition
| wrist extension to maximum for 60 seconds |
|
|
Term
|
Definition
| tapping over transverse carpal ligament |
|
|
Term
| what is the provocation test? |
|
Definition
| compress and hold over transverse carpal ligament |
|
|
Term
| what does finkelstein's test test for? |
|
Definition
DeQuervain’s tenosynovitis
Extensor pollicis brevis
Abductor pollicis longus
More common in females
Repetitive movements of thumb |
|
|
Term
| describe soft tissue direct technique |
|
Definition
Soft tissue technique is a direct technique that usually involves lateral stretching, linear stretching, deep pressure, traction and/or separation of muscle origin and insertion while monitoring tissue response and muscle changes by palpation.
Directed at tissues other than skeletal or arthrodial
Usually involves lateral / linear stretching, and/or deep pressure, traction and/or separation of muscle origin & insertion while monitoring tissue response & motion changes by palpation.
Therapeutic goal: muscular & fascial relaxation |
|
|
Term
| what are the proposed mechanisms of soft tissue technique? |
|
Definition
Relaxes hypertonic muscles and reduce spasm
Stretches and increases the elasticity of shortened fascial structures
Enhances circulation to local myofascial structures
Improves local tissue nutrition, oxygenation, and removal of metabolic wastes
Improves abnormal somato-somatic and somato-visceral reflex activity, thus improving circulation in areas of the body remote from the area being treated
Identifies areas of restricted motion, tissue texture changes and sensitivity
Improves local and systemic immune response
Provides a general state of relaxation
Provides a general state of tonic stimulation by stimulating the stretch reflex in hypotonic muscles |
|
|
Term
| what are the indications for soft tissue technique? |
|
Definition
Somatic dysfunction of the soft tissues of the body as characterized or inferred by asymmetry, restriction of motion, tissue texture changes and tissue tenderness:
hypertonic muscles
excessive tension in fascial structures
abnormal somato-somatic and somato-visceral reflexes
Clinical conditions that would benefit from:
enhanced circulation to local myofascial structures
improved local tissue nutrition, oxygenation, and removal of metabolic wastes
improved local and systemic immune responsiveness
As an adjunct to additional manipulative treatment in order to:
identify other areas of somatic dysfunction
observe tissue response to the application of manipulative technique
provide a general state of relaxation
provide a general state of tonic stimulation
prepare tissues for other types of manipulation |
|
|
Term
| what are some contraindications for soft tissue technique? |
|
Definition
Absence of somatic dysfunction
Lack of patient consent and/or cooperation
Skin: Disorders which would preclude skin contact, e.g., contagious skin diseases, acute burns, painful rashes, abscesses, skin cancers, etc.
Fascia: Acute fasciitis (infectious or autoimmune), acute fascial tears
Muscle: Acute muscular strains, acute myositis, muscle neoplasms.
Ligament: Acute ligamentous sprain, acute ligamentous inflammatory disorders, septic arthritis, primary or secondary joint neoplasms.
Bone: Acute fracture, osteomyelitis, primary or secondary bone tumors, osteoporosis
Viscera: Infectious or neoplastic enlargement of organs such as the liver and spleen. Gastric or bowel obstruction or distention. Acute organ pain, e.g., pyelonephritis. Undiagnosed abdominal or pelvic pain.
Vascular: Hematoma, deep venous thrombosis, uncontrolled bleeding disorders |
|
|
Term
| describe the different principles of treatment for soft tissue technique |
|
Definition
Soft tissue technique is a passive direct technique.
There are three basic mechanisms used in applying soft tissue technique.
1. Tractional technique, also called stretching, in which the origin and insertion of the myofascial structures being treated are longitudinally separated.
2. Kneading, a rhythmic, lateral stretching of a myofascial structure, in which origin and insertion are held stationary and the central portion of the structure is stretched like a bowstring.
3. Inhibition, sustained deep pressure over a hypertonic myofascial structure.
Other mechanisms used on more superficial fascial structures include variants on techniques developed in the European massage movement:
Effleurage
Petrissage
Tapotement
Skin Rolling |
|
|
Term
| what is myofascial release? |
|
Definition
| Myofascial release (MFR) is a system of diagnosis and treatment, first described by Andrew Taylor Still and his early students, which engages continual palpatory feedback to achieve release of myofascial tissues. |
|
|
Term
| what is the difference between direct and indirect myofascial release? |
|
Definition
Direct MFR, a myofascial tissue restrictive barrier is engaged for the myofascial tissues and the tissue is loaded with a constant force until tissue release occurs.
Indirect MFR, the dysfunctional tissues are guided along the path of least resistance until free movement is achieved. |
|
|
Term
| what are the proposed mechanisms for myofascial release? |
|
Definition
Fascia is capable of changes in length (plasticity and elasticity), with associated changes of energy content (hysteresis).
MFR provides peripheral neuroreflexive alterations in muscle tone and neural facilitation, in part, by its influence on mechanoreceptors.
The application of MFR allows for connective tissue plastic changes (creep) which are associated with release of energy. This may include heat, electromagnetic, and piezoelectric changes.
External forces applied to fascia facilitate restoration of normal structure and function.
Tensegrity principles coupled with fascial bioelectric (piezoelectric) properties influence the anatomical and physiological responses of tissues to applied manipulative forces. |
|
|
Term
| what are the indications and contraindications for myofascial release? |
|
Definition
Indications
MFR is used to treat somatic dysfunctions involving myofascial or other connective tissues.
Contraindications
Absence of somatic dysfunction
Lack of patient consent and/or cooperation
Extreme caution should be exercised in patients with fractures, open wounds, acute thermal injury, soft tissue or bony infections, abscesses, deep venous thrombosis (threat of embolism), anticoagulation, disseminated or focal neoplasm, recent post-operative states over the site of proposed treatment (wound dehiscence), and aortic aneurysm. |
|
|
Term
| what are the principles of treatment for indirect myofascial release? |
|
Definition
Movement of a patient by the physician into the position of ease for all planes, following any tissue release or fascial unwinding until completed. If needed to enhance tissue release, the following may be employed:
1. Regional compression, distraction, or torsion
2. Tissue inhibition or traction
3. Respiratory cooperation in the phase which encourages tissue relaxation
4. Eye, tongue, jaw, head or limb movements |
|
|
Term
| what are the principles of treatment for direct myofascial release? |
|
Definition
Movement of a patient by the physician into the restriction for all planes, applying steady force until tissue release or fascial unwinding is completed. If needed to enhance tissue release, the following may be employed:
1. Respiratory cooperation in the phase which encourages tissue tension
2. Tissue inhibition
3. Oscillation
4. Eye, tongue, jaw, head or limb movements |
|
|
Term
| what are some special considerations for myofascial release? |
|
Definition
MFR may be performed on various tissues including fascia, tendons, cicatrices (scars), internal organs, or visceral suspensory ligaments.
MFR decreases myofascial tone at a segmental level in treating spinal somatic dysfunction. |
|
|
Term
| what is articulatory treatment (ART)? |
|
Definition
Low velocity/high amplitude
A technique in which an articulation is taken through it’s full range of motion with specific attention directed at the dysfunctional barrier(s)
The therapeutic goal is increased freedom of articular motion |
|
|
Term
|
Definition
Low velocity/high amplitude
A technique in which the restrictive barrier is engaged repeatedly to produce an increased freedom of motion
The therapeutic goal is increased freedom of articular motion |
|
|
Term
|
Definition
| A form of osteopathic manipulative diagnosis and treatment in which the patient’s muscles are actively used on request, from a precisely controlled position, in a specific direction, and against a distinctly executed physician counterforce. |
|
|
Term
| what is the proposed mechanism of muscle energy? |
|
Definition
| A system of practice which uses physician-guided, voluntary muscle contraction to treat a specific mechanical diagnosis. The technique can be used to restore normal muscle tone and/or improve joint mechanics. |
|
|
Term
| what is the goal of post iosmetric relaxation? |
|
Definition
Goal: To accomplish muscle relaxation
Physiologic Basis: Mitchell Jr. postulated that immediately after an isometric contraction, the neuromuscular apparatus is in a refractory state during which passive stretching may be performed without encountering strong myotatic reflex opposition. All the physician needs to do is resist the contraction, and then take up the soft tissue slack during the refractory period.
Force of Contraction: Sustained gentle pressure |
|
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Term
| what is the goal of joint mobilization using muscle force? |
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Definition
Goal: To accomplish restoration of joint motion in an articular dysfunction
Physiologic Basis: Distortion of articular relationships and motion loss results in a reflex hypertonicity of the musculature crossing the dysfunctional joint, similar to thrust (HVLA) technique. This increase in muscle tone tends to compress the joint surfaces and results in thinning of the intervening layer of synovial fluid and adherence of joint surfaces. Restoration of motion to the articulation results in a gapping, or reseating of the distorted joint with reflex relaxation of the previously hypertonic musculature.
Force of Contraction: Maximal muscle contraction that can be comfortably resisted by the physician |
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Term
| what is the goal of respiratory assistance? |
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Definition
Goal: To produce improved body physiology using the patient’s voluntary respiratory motion.
Physiologic Basis: The muscular forces involved in these techniques are generated by the simple act of breathing. This may involve the direct use of the respiratory muscles themselves, or motion transmitted to the spine, pelvis, and extremities in response to ventilation motions. The physician usually applies a fulcrum against which the respiratory forces can work.
Force of Contraction: Exaggerated respiratory motion |
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Term
| what is the goal of the oculocephalogyric reflex? |
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Definition
Goal: To effect reflex muscle contractions using eye motion.
Physiologic Basis: Functional muscle groups are contracted in response to voluntary eye motion on the part of the patient. These eye movements reflexively affect the cervical and truncal musculature as the body attempts to follow the lead provided by eye motion. It can be used to produce very gentle post-isometric relaxation or reciprocal inhibition.
Force of Contraction: Exceptionally gentle |
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Term
| what is the goal of reciprocal inhibition? |
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Definition
Goal: To lengthen a muscle shortened by cramp or acute spasm.
Physiologic Basis: When a gentle contraction is initiated in the agonist muscle, there is a reflex relaxation of that muscle’s antagonistic group.
Force of Contraction: Very gentle |
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Term
| what is the goal of the crossed extensor reflex? |
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Definition
Goal: Used in the extremities where the muscle that requires treatment is in an area so severely injured (e.g., fractures or burns) such that manual contact with the affected limb is inadvisable.
Physiologic Basis: This form of muscle energy technique uses the learned cross pattern locomotion reflexes engrammed into the central nervous system. When the flexor muscle in one extremity is contracted voluntarily, the flexor muscle in the contralateral extremity relaxes and the extensor contracts.
Force of Contraction: Very gentle |
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Term
| describe the different types of muscle contractions |
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Definition
ISOMETRIC MUSCLE CONTRACTION
Most common form of contraction used in muscle energy technique. The origin and insertion of the muscle are maintained in a stationary position while the muscle is contracted against resistance.
Maintains constant muscle length (no winners)
ISOTONIC MUSCLE CONTRACTION
This basic principle is applied to joint restriction by activating a specific muscle while fixing only one end of the muscular attachment, with the goal of restoring normal mechanics.
Hypotonic, reflexively inhibited muscles are frequently treated with isotonic contractions.
Muscle length shortens (patient wins)
ISOLYTIC MUSCLE CONTRACTION
Used for the treatment of fibrotic or chronically shortened myofascial tissues. The applied counterforce is greater than the patient force, resulting in lengthening of the myofascial tissues.
Muscle length elongates (dr wins) |
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Term
| what are the types of joint restrictors? |
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Definition
MONOARTICULAR MUSCLES
Also referred to as short restrictors, considered key in maintaining Type II, segmental dysfunctions
POLYARTICULAR MUSCLES
Also referred to as long restrictors, considered to maintain Type I, group dysfunctions |
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Term
| what are the indications and contraindications for muscle energy? |
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Definition
Indications
Clinically relevant somatic dysfunction
Contraindications
Absence of somatic dysfunction
Lack of patient consent and/or cooperation
Infection, hematoma, or tear in involved muscle
Fracture or dislocation of involved joint
Rheumatologic conditions causing instability of the cervical spine
Undiagnosed joint swelling of involved joint
Positioning that compromises vasculature |
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Term
| what are the principles of treatment for muscle energy? |
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Definition
Principles of Treatment
Key steps for successful direct muscle energy techniques:
Accurate specific diagnosis of somatic dysfunction
Position the patient at the point of initial resistance (―feather’s edge) of the barrier
Physician must establish an appropriate counterforce
Patient introduces appropriate muscle energy effort
Direction
Duration (usually 3 – 5 seconds)
Amount of force
The patient must completely relax following muscle effort
A pause of 1-2 seconds is necessary for neuromuscular adaptation (post-relaxation phase)
Physician must reposition the patient at the new restrictive barrier
Repeat steps 3-6 until no further change is obtained
Reassess for appropriate change |
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Term
| what are some special considerations for muscle energy? |
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Definition
Special Considerations
Muscle energy technique is the prototypical active, direct osteopathic manipulative technique.
Muscle energy technique can be used to treat any joint that is crossed by voluntary muscles.
Muscle contraction is a principle mechanism for promoting lymphatic and venous circulation, thereby making muscle energy technique important in the treatment of edema/congestion. This in turn may result in secondary reduction of inflammation. |
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Term
| what is HVLA and what are its proposed mechanisms? |
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Definition
An osteopathic technique employing a rapid, therapeutic force of brief duration that travels a short distance within the anatomic range of motion of a joint, and that engages the restrictive barrier in one or more planes of motion to elicit release of restriction. Also known as thrust technique.
Proposed Mechanism(s)
Restoration of joint motion
Vacuum theory/Cavitation
Microadhesions
Decreases facilitation/nociception/elevated mechanoreceptor activity |
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Term
| what are some indications for HVLA? |
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Definition
Articular Somatic Dysfunction (TART)
Firm distinct articular barrier
Note: The “end feel” must be solid. Without a distinct barrier specific localization of forces will be difficult and the technique will not work. |
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Term
| what are the contraindications for HVLA? |
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Definition
Contraindications
Absolute (regionally or segmentally specific)
Rheumatoid arthritis
Down syndrome
Achondroplastic dwarfism
Chiari malformation
Fracture / dislocation / spinal or joint instability
Ankylosis / Spondylosis with fusion
Surgical fusion
Klippel-Feil syndrome
Vertebrobasilar insufficiency
Neurological symptoms during testing or localization
Inflammatory joint disease
Joint infection
Bony malignancy
Patient refusal
Medicolegal situations
Relative (regionally or segmentally specific)
Acute herniated nucleus pulposus
Acute radiculopathy
Acute whiplash / severe muscle spasm / strain/sprain
Osteopenia / Osteoporosis
Spondylolisthesis
Metabolic bone disease
Hypermobility syndromes |
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Term
| what are the principles of treatment for HVLA? |
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Definition
Accurate diagnosis
Choice of force vector
Short Lever – Force applied directly at level of dysfunction
Long Lever – Forces directed from a distance to the level of dysfunction
Specific engagement of restrictive barrier
in involved planes of motion
not overloading tissues
without causing patient guarding
Maintain localization throughout the thrust
Balance and control
No ―backing off‖ or ―winding up‖
Apply HVLA thrust
Minimal force, short distance, rapid acceleration / short duration without hesitation
Re-assessment |
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Term
| what are some precautions that should be taken while performing HVLA? |
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Definition
Do not disengage the barrier before applying the final corrective force.
You must localize forces to the area of dysfunction.
Excessive dosage can result in hypermobility.
Manipulation is employed to restore normal motion. Do not manipulate areas of hypermobility or instability |
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Term
| how would a physician perform direct myofascial release? |
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Definition
Pt seated, Doc behind patient
Place hands over shoulders at base of neck
Monitor left & right rotation / torsion for ease of motion
Apply gentle force into barrier until:
20 – 60 seconds
Tissue release
Reassess |
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Term
| what are the steps used for muscle energy treatment? |
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Definition
Position the patient against the restrictive barrier in all planes of motion
The patient tries to return to neutral
The doctor resists the return with equal force (no winner)
Both parties relax
Return to step 1 (repeat 3-4 times) |
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Term
| how would a physician perform transtarsal somatic dysfunction HVLA? |
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Definition
Patient position: supine
Physician position: standing beside the table on side of the somatic dysfunction
The physician places the patient’s knee in flexion, abduction, and external rotation
The physician places the thenar eminence of one hand over the calcaneus while the other hand is place over the first metatarsal and talus
Exert a counter-clockwise rotary thrust with the hand holding the talus while simultaneously exerting a downward thrust through the calcaneus with the other hand |
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Term
| who founded allopathic medicine? |
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Definition
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Term
| who founded homeopathic medicine? |
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Definition
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Term
| what is eclectic medicine? |
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Definition
| Eclectic medicine was a schism of the Thomsonian reform (founded by Samuel Thomson) movement of the early nineteenth-century, in the United States. Eclectic medical schools used the Doctor of Medicine (MD) degree. Thomson believed in herbs and plants that grew towards the light, the source of life, and rejected minerals since they came from the ground that is cold, which signifies sickness and death. The eclectic physicians believed in concentrated medications. They treated the patient’s symptoms and not the disease. |
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Term
| what is homeopathic medicine? |
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Definition
| Homeopathic medicine was founded by Samuel Hahnemann in the late eighteenth-century, in Germany. Homeopathic medical schools use the Doctor of Medicine (MD) degree. Homeopaths believe in the rule of similars – like-cures-like. (homeo = same + pathos = suffering). They also believe in the law of infinitesimals – the more diluted the dose the more powerful the medication. Homeopathy in America reached its zenith in 1901 with twenty-two homeopathic medical schools. |
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Term
| what is physiomedical medicine? |
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Definition
| Physiomedical medicine was another schism from the Thomsonian reform movement. They broke from the Thomsonian movement later than the eclectics; they were poorly trained, and offered no lasting contribution to medicine. At their zenith in the early 1900s the physiomedicals had only three medical schools and by the time of the Flexner report in 1910 only one school remained and that school closed shortly afterwards. |
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