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244 Cards in this Set

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List the 7 steps for treating counterstrain.
1. Find most significant tender point
2. Establish scale (10 = start)
3. Monitor tenderness, tissue texture
4. Passively move patient toward ease, until pain reduced 70% or more
5. Maintain for 90 seconds, rechecking every 30 seconds, monitor
6. Slowly return PASSIVE patient to pretreatment position, maintain contact with point
7. Re-evaluate for resolution of tenderness and tissue abnormality at tender point.
What are three things that are shared between trigger and tender points?
1) Both can be located in muscle (though tender points not necessarily)
2) Locally tender
3) Elicits jump sign when pressed
What characteristics are unique to TENDER points?
NO associated pain pattern, located in muscles tendons ligaments and fascia, NO radiating pattern when pressed, taut band is NOT present, twitch response is NOT present, dermographia NOT present, Jones felt a tender point was a MANIFESTATION of a dysfunction, muscle treated by SHORTENING
What characteristics are unique to TRIGGER points?
Patient presents with characteristic pain pattern, elicits a radiating pain pattern when pressed, present within a taut band of tissue, elicits twitch response with snapping palpation, dermographia of skin over point, Travell felt pathology WAS the trigger point, muscle treated by stretching spraying and injection.
What is somatic dysfunction?
Impaired or altered function of related components of the somatic system (body framework): skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elementss
What is a dermatome?
An area of skin innervated by sensory fibers from a single spinal nerve.
What is a sclerotome?
A group of mesenchymal cells emerging from the ventromedial part of a mesodermic somite and migrating toward the notochord.
What is a motor point?
The place where an alpha motor neuron pierces the investing fascia of a muscle to innervate a muscle
What kind of technique is Counterstrain?
Indirect, passive technique.
What are the two phases in treating a patient with Counterstrain?
Phase 1 – use subjective tenderness from patient to guide treatment
Phase 2 – use your developing palpatory skills to identify and monitor the tissue texture abnormalities of the tender point and correlate them with the patient’s reported tenderness.
What are the six stages in a normal muscle going to a dysfunctional resting state (tender point) and back to normal with treatment?
1. Normal
2. Production of Strain
3. Reaction to Strain
4. Dysfunctional Resting State
5. Counterstrain Treatment
6. Post-Treatment
Describe how the dysfunctional state treatable by Counterstrain is produced.
A normal muscle is stretched and strain is produced, creating pain and a sudden panic shortening of that longer muscle. This results in stretch inhibition of the agonist muscle, and reflex contraction and sustained hypertonus (facilitated spindles) of the antagonist.
How does Counterstrain affect the dysfunctional state?
The muscles are gently stretched, reproducing the situation that caused the strain, but allows for a resetting reflex, forcing the antagonist muscle down to zero firing. When brought back to normal position passively, there is no stretch inhibition or reflex contraction. SD is resolved.
What tenderpoint(s) are associated with...
Frontal Headache
Periorbital Headache
Occipital to Vertex Headache
Temporal Headache
Generalized Headache
Frontal Headache: C1;
Periorbital Headache: C2;
Occipital to Vertex Headache: C4;
Temporal Headache: C2
Generalized Headache: C5
What tenderpoint(s) are associated with...
Whiplash
Earache, Tinnitis, Vertigo
Maxillary Sinus Pain
Lower Neck Pain
Cervical Motion Restriction
Whiplash - C1-C2, C7-C8, T1-T2
Earache, Tinnitis, Vertigo - C3
Maxillary Sinus Pain - C2
Lower Neck Pain - C6-C8
Cervical Motion Restriction - any C
What tenderpoint(s) are associated with...
Upper Back Pain
Precordial Pain
Fatigue
Cystitis
Upper Back Pain - T1-T6
Precordial Pain - AT3-6, ribs, interspace
Fatigue - T5-T6
Cystitis - AT11, L4
What tenderpoint(s) are associated with...
Heartburn
Epigastric Pain
Umbilical Pain
Diarrhea or Constipation Pain
Heartburn - AT5
Epigastric Pain - AT7-8
Umbilical Pain AT9-10
Diarrhea or Constipation pain AT9-10
What tender point(s) are associated with...
Shoulder pain/numbness
Finger pain
Elbow pain
Lower Back pain
Shoulder pain/numbness - AT1-5
Finger pain - C6-8, T1
Elbow pain - T1
Lower Back pain - T9-T12
What is a therapeutic pulse?
Prior to release of the muscle, the operator will sense warmth at the tender point.
What is a Maverick tender point?
An atypical strain point
Define a "stoic" patient.
Stoic patient - one who reports no pain or change in pain with positional movements, one has to rely on feel of tissue rather than patient feedback.
What are some indications for Counterstrain?
Acute/chronic SD, SD with neural component like hypertonic myofascial tissue, as a primary treatment or combined with other techniques, SDs in many areas of the body.
What are some relative contraindications for Counterstrain?
Patients who cannot voluntarily relax, are severely ill, vertebral artery disease, severe osteoporosis
How many patients experience treatment reactions, and what kind of reactions do they have?
20-30% of patients experience a reaction, general soreness, usually after their first treatment, appears 1-48 hours after treatment. Resolves in 1-2 days. Treating 6 or less tender points reduces the risk of reaction.
What are some patient instructions following a Counterstrain treatment?
Avoid painful motions, avoid recreating the injury, avoid extremes of motion, do not test motions that produced pain or restriction before treatment, stay well hydrated (7-10 glasses of water), avoid dehydrating liquids.
How should one go about a Counterstrain treatment regimen and follow-up?
Patient followup should be within 3-7 days at first, increasing distance between treatments as patient improves. Only one treatment may be necessary, but may take 6-10 over 2-3 months.
What are the pelvic tender point manifestations of dysmenorrhea?
MPSI - Midpole Sacroiliac
FISI - Flarein Sacroiliac
What are the pelvic tender point manifestations for low back pain?
ILA - Iliacus
SI points - Sacroiliac
What are the pelvic tender point manifestations for sciatica?
PIR - Piriformis
What are the pelvic tender point manifestations for hip and thigh pain?
SI points - Sacroiliac
What are the pelvic tender point manifestations for coccygodynia?
HISI - High Ilium Sacroiliac
HIFO - High Ilium Flareout
What are the pelvic tender point manifestations for groin pain?
ING - Inguinal
What additional parts of the body should be considered when evaluating a pelvic somatic dysfunction?
Thoracic spine, Lumbar spine, lower extremities
Where is the Iliacus tender point located? Is it anterior or posterior?
Iliacus now includes the psoas and iliacus points.

Iliacus - 1/3 distance to midline from the ASIS
Psoas - 2/3 distance to midline from the ASIS

Anterior
Where is the low ilium tender point located? Is it anterior or posterior?
It is found on the anterior surface of the pubic ramus, where the medial thigh intersects the pubic ramus, lateral to the pubic tubercle.

Anterior
Where is the inguinal ligament tender point located? Is it anterior or posterior?
It is found on the superior aspect of the pubic ramus, at the attachment of the inguinal ligament.

Anterior
Describe the treatment position used to treat the Iliacus and Psoas tender points.
Patient lays supine, ankles crossed over knee of physician, ankle on treatment side against the knee. Patient relaxes thighs to allow knees to fall laterally.

Physician induces flexion and external rotation
Describe the treatment position used to treat the Low Ilium tender point.
Patient lays supine, physician brings knee on treatment side cephalad, carefully monitoring point.

Physician induces flexion and a little external rotation if needed.
Describe the treatment position used to treat the Inguinal ligament tender point.
Patient lays supine, with knees crossed and treatment leg resting on the physician's knee.

Physician induces flexion and internal rotation.
What direction, flexion or extension, is used for the anterior pelvic tender points?
Flexion
Where is upper pole L5 tender point located? Is it anterior or posterior?
It is on the superior-medial aspect of the PSIS

Posterior
Where is the high ilium sacroiliac tender point located? Is it anterior or posterior?
The HISI is on the lateral side of the PSIS

Posterior
Where are the posterior lumbar 3 and posterior lumbar 4 tender points located? What muscle(s) are thought to be involved?
PL3 is about halfway between PL4 and the PSIS
PL4 is halfway between the greater trochanter and the iliac crest, and in line with the PSIS at the posterior aspect of the tensor fascia lata.

Gluteus medius
What pelvic tender points are in Group IA?
UPL5, HISI, PL3, PL4
Describe the treatment position used to treat tender point UPL5.
Patient lays prone, physician brings leg into extension, with some external rotation and adduction.
Describe the treatment position used to treat tender point HISI.
Patient lays prone, physician brings leg into extension, with some abduction.
Describe the treatment position for tender points PL3, PL4
Patient lays prone and physician extends the treatment leg, with some external rotation and abduction or adduction.
What pelvic tender points are in group 1B?
MPSI, FISI, HIFO
Where is the midpole sacroiliac tender point located? Is it posterior or anterior?
It is directly below the PSIS and at the level of the ILA.

Posterior
Where is the flarein sacroiliac tender point located? Is it posterior or anterior?
The FISI point is also called the MPSI point, and is located directly below the PSIS and at the level of the ILA.

Posterior
What is the treatment position for MPSI or FISI tender points?
Patient lays prone, physician abducts the leg, with some extension or flexion.
Where is the high ilium flareout tender point? Is it posterior or anterior?
HIFO is located on the lateral side of the coccyx.

Posterior
What is the treatment position for a HIFO tender point?
Patient lays prone, physician extends an appropriate amount and adducts the leg.

Posterior
What pelvic tender points are in group 2?
MPSI, FISI, LPL5, PIR,
Where is the lower pole L5 tender point located? Is it posterior or anterior?
LPL5 is 2cm below the PSIS, on the inferior aspect.

Posterior
What is the treatment position for a LPL5 tender point?
Patient lays prone, physician usually seated beside patient on treatment side, flexes treatment leg off edge of table and internally rotates and adducts if necessary.
Where is the piriformis tender point located? Is it anterior or posterior?
PIR is located halfway between the ILA and the greater trochanter, in the middle of the piriformis muscle.

Posterior
What is the treatment position for a piriformis tender point?
Patient lays prone, physician usually is seated on treatment side of patient, and flexes the knee off the table, with some abduction and internal rotation.
What is the palpation vector for the PSO and ILA tender points?
Anterior to posterior, 2-3 inches deep
What is the palpation vector for the LI and ING tender points?
Anterior to posterior
LI - medially
ING - superiorly
What is the palpation vector for the UPL5 tender point?
Inferior and lateral
What is the palpation vector for the PL3 and PL4 tender points?
lateral to medial, posterior to anterior
What is the palpation vector for the HISI tender point?
lateral to medial, some posterior to anterior
What is the palpation vector for the HISI tender point?
Press at a 45 degree angle, lateral to medial
What is the palpation vector for the PIR tender point?
Posterior lateral to anterior medial
What is the palpation vector for the LPL5 tender point?
Superior and posterior to anterior
Describe (general) the reciprocal tension membrane?
There are three layers of living membrane: dura mater, arachnoid mater, pia mater;

Each layer has differing strengths and structure, supports the CNS rostrally to caudally.
Describe the straps formed from the folds of the reciprocal tension membrane
The RTM folds back on itself to form internal straps...
...between the two halves of the brain
...between the brain and pituitary
...between the cerebrum and cerebellum
Describe the three layers of the RTM.
Pia mater - a thin membrane adhering directly to the cells of the CNS
Arachnoid mater - a complex layer of spiderweb-like filaments that contain CSF - and lies between the dura mater and pia mater.
Dura mater - the outer layer that adheres to the bone and to itself to form venous sinuses, the diaphragma sellae, tentorium, and falx.
What are the names of the internal straps in the skull formed by the RTM?
Falx Cerebri, Falx Cerebelli, Diaphragma Sella, Anterior Dural Girdle
What are the sinuses in the tentorium cerebelli?
Transverse sinus, straight sinus, superior petrosal sinus, inferior petrosal sinus, cavernous sinus, spheno-parietal sinus
What are the sutures, eminences, and fontanelles of the skull?
Sutures: Coronal, Frontal/Metopic, Lambdoid, Sagittal
Fontanelles: Anterior, Posterior, Posteriolateral/Mastoid, Anterolateral/Sphenoidal
Eminences: Parietal, Frontal
What are vault bones? What is the "boss" or "eminence" in adults?
Vault bones are the plates of bones that make up the skull

Each starts at an ossification system, bones grow by radiating outward, and collide with one another to push the skull wider apart.

"Boss" or "eminence" of adult bones are the old ossification centers.
What is squamous bone? What is basilar bone?
Squamous bone - when bone forms within the membrane of the Dura. Thin, with few fenestrations or foramina.

Basilar bone: also called basement bone, thick, with many foramina
Are the temporal and occipital bones basilar or squamous?
They both have a basilar portion (basi-occiput) and a squamous (temporal squama) portion - each bone contributes to the cranial base and the vault.
How does bone vault growth affect the dura?
As the bones grow, they drag out the dura, stretching it, which is important for keeping the sinuses patent.
What are the five parts of the "star formation" of the dura?
Crista galli (center) - lateral to that, the Lesser Wings (one on each side) - even more lateral, the petrous portions (one on each side)
What are the poles of attachment for the RTM?
Crista galli - the anterior/posterior pole
Clinoid processes - anterior/inferior pole
Petrous ridges - lateral poles
Sacrum - caudal pole
Occiput - posterior pole
What folds are associated with which sinuses in the RTM/dura? Include those not necessarily associated with folds.
Falx cerebri - superior and inferior sagittal sinuses
Falx cerebelli - occipital sinus
Tentorium cerebelli - transverse sinus
Great vein of Galen
Sutherland's fulcrum - straight sinus
Confluence of sinuses
Sigmoid sinus
Cavenrous sinus
List the sinuses along the cranial base (5)
Straight sinus
Confluence of sinuses
Transverse sinus
Sigmoid sinus
Cavernous sinus
What empties into the straight sinus?
Inferior sagittal sinus and great vein of Galen
What empties into the confluence of sinuses?
Across the skull from the inion, it collects blood from the occipital, straight, and superior sagittal sinuses
What empties into the sigmoid sinus?
Transverse and petrosal sinuses, which are sent to the jugular vein via the sigmoid sinus
Where is the cavernous sinus and into what does it drain?
It is located at the pituitary gland (nestled around it) and drains into the petrosals.
What two sinuses does the transverse sinus connect?
Confluence of sinuses to the sigmoid sinus.
How do the dural membranes interface with the spine?
The dura is continuous with the internal layer of cranial dura.
It is firmly attached to the foramen magnum C2, C3, and S2.
It becomes the denticulate ligament that surrounds the exiting nerve root
At what three points along the spine is the dural membrane not continuous?
C2, C3, S2
How does one use the RTM to enhance motion?
Move the contralateral piece in the opposite direction to enhance motion in the desired direction
What is the only part in the RTM/sinus network/etc that does not move during the CRI motions?
The straight sinus remains static - it transmits tension without motion.
What are the common findings for S2, C2, and the occiput?
S2, C2 and occiput are usually rotated and sidebent together. They are also corrected together (as opposed to treating each individually)
What characteristics are found in the RTM when in flexion?
SBS rises
Pulling anterior sacrum rostrally (L5-S1 goes posterior)
Inferior sagittal sinus drops
Straight Sinus remains still
Head widens
Glabella moves towards Inion
What are some things to remember about sutures/cranial joints?
Sutures exist and are patent throughout life

Joints take work to create and maintain

Only reason to maintain them is for motion
How is cranial motion affected when there is...
...no suture?
...a complex suture?
...a bone in a suture?
No suture = no motion (cranial synostosis)
Complex suture = complex motion
Bone in a suture = distorted motion
What are some characteristics of sutures?
Do not form until the bones meet in infancy
Interdigitate with each other
Change bevel with each other
Regarding cranial bones, what are the effects of...
...hypermobility?
...normal motion?
...hypomobility?
Hypermobility = speculated to cause wormian bones
Normal motion = produces beveled sutures
Hypomobility = produces ankylosis
What is the "West Coast Model" with regards to suture sand membranes in OMT?
bones inter-digitate at sutures, and lesions release along sutural lines. Treat each bone in detail, focus on the sutures & their bevels
Regarding cranial sutures and membranes, what is the "East Coast Model"?
bones can only do what the membranes in which they live permit. Sutures & their bevels are less important than accessing membranous restrictions
When the primary respiratory mechanism is in the exhalation phase, what motion would the sphenobasilar symphysis exhibit?
Extension

*Midline bones only flexion or extension*
In a freely mobile cranium, the sphenoid rotates around what type of axis with flexion in the PRM?
(forgot, look up)
In a freely mobile cranium, what direction would you expect the greater sphenoid wings to move when the sphenoid moves into flexion?
Inferior
In a freely mobile cranium what motion would you expect the temporal bones to exhibit when the PRM is in inhalation phase?
External Rotation
What motion would you expect the sacral base to exhibit when the SBS is flexing?
Posterior and Superior
What are the five component phenomena of the primary respiratory mechanism?
1) Central nervous system (CNS) inherent motility
2) Cerebral spinal fluid (CSF) rhythmic fluctuations
3) Intracranial and intraspinal membranes (dura) inherent mobility
4) Articular mobility of the osseous cranial bones
5) Sacrum involuntary articular mobility relative to the ilia
What are the Pared Bones? What drives them? (Pared bone - bone that drives them)
Frontals - RTMs
Parietals - RTMs
Temporals - Occiput
Zygoma - Temporal bones
Maxillae - Vomer bone

Others: Palatines, nasals, lacrimals, inferior conchae, ethmoid (lateral masses)
What are the Midline Bones?
Sphenoid*
Occiput*
Ethmoid (median plate)
Vomer
Sacrum
About what axis does flexion of the sphenobasilar symphysis occur?
The parallel transverse axis
If the sphenoid rotates inferior, then in what direction do the ethmoid and occiput rotate?
Superior
How is rotation of the ethmoid and occiput related?
They rotate in the same direction
How is rotation of the ethmoid and occiput related to the sphenoid?
Ethmoid and occiput rotate one way, sphenoid in the other
In what direction does the SBS move during inhalation phase of the PRM? Is this flexion or extension?
The SBS rises

Inhalation phase of the PRM is correlated with Flexion
In what direction does the SBS move during exhalation phase of the PRM? Is this flexion or extension?
The SBS falls

Exhalation phase of the PRM is correlated with Extension
What is the Vault Hold? On what bones are the fingers placed?
Patient supine, operator seated and the four fingers along the side of the head on each side.

Digit 2 - the greater wing of the sphenoid
Digit 3 - temporal bone zygomatic arch
Digit 4 - behind the ear on the temporal bone mastoid process
Digit 5 - lateral angle of the occiput
What is the Core Link?
a functional as well as anatomical integrative relationship within the primary respiratory mechanism that directly connects the cranium to the sacrum (The occiput, C2, C3, and Sacrum).

Achieved through the dural column
Describe the link that is very clinically useful between the cranium and the sacrum and pelvis.
The core link uses the mobility of the intracranial and intraspinal membranes, and the involuntary mobility of the sacrum between the ilia.
What are four occiput developmental considerations?
Formed from four distinct embryological parts - squamous portion with subparts - interparietal, supraocciput - there are two condylar portions, and two basilar portions.
By what year does the occiput fuse?
7th or 8th year
About what axis does the sacrum rotate?
The sacrum rotates about the transverse respiratory axis - at the tip of the spinous process of the second sacral segment.
How does the sacrum move during primary respiration?
With occiput flexion phase, the base of the sacrum moves posteriorly about the primary axis and slightly superior

Extension phase moves the base slightly inferior and anterior
What are some symptoms of condylar compression in a newborn?
Inability to latch and suck, frequent emesis, bradycardia, torticollis (neck to one side), irritability, colic, opisthotonis (can't lay flat)
What is HVLA?
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.
What is the goal of HVLA manipulation?
To restore pain-free movement to the musculoskeletal system in postural balance.
What are some consequences of SD?
Decreased mechanical efficiency/increased joint stress
Facilitation of spinal segments
Soft tissue contractures (overuse, disuse)
Decreased ROM
Pain
What is a good technique to use before using HVLA
Soft tissue techniques help prepare the area of SD for treatment
What three professions use HVLA?
Osteopathic medicine, Chiropractic medicine, Physical therapy
Define articulatory technique. What is the activating force?
a low velocity/moderate to high amplitude technique where a joint is carried through its full motion with the therapeutic goal of increased range of movement.

The activating force is either a repetitive springing motion or repetitive concentric movement of the joint through the restrictive barrier.
Define springing technique.
A low velocity/moderate amplitude technique where the restrictive barrier is engaged repeatedly to produce an increased freedom of motion.
List the variations of HVLA, including HVLA (4).
Thrust - HVLA

Springing - Decreased force application, repeated addressing of barrier

Articulatory - low velocity/moderate amplitude

Low Velocity, High Amplitude - Increased force more slowly
What are a few synonyms for HVLA?
High velocity Low amplitude, Thrust, Mobilization, Impulse, Crunch, Cracking, Popping
How is HVLA, as a technique, classified?
Direct action, passive
What are some indications for HVLA?
Specific joint restriction (ROM)

Hard barrier
What are some relative contraindications for HVLA?
Cancer
Mild-moderate osteoporosis
Neurological disease (cerebral palsy, Parkinson's, etc)
Extremes of age - Toddlers, Geriatric patients
What are some absolute contraindications for HVLA?
Vertigo or loss of consciousness with cervical extension and rotation, indication of vertebral artery occlusion
"Rubbery" quality of soft tissue restriction
Pathologic instability of the O/A joint (ie RA, Down Syndrome/Trisomy 21)
Suspicion of a fracture
Septic joint
Vasculitis, Bursitis, History of CVA
Metastatic bone disease
What are the goals / expected or desired results with HVLA?
Immediate increase in the range and freedom of motion
What is the approximate amplitude of the thrust in HVLA?
1/8 inch
List the 5 basic steps of HVLA treatment
1) Prepare dysfunctional joint by relaxing associated soft tissue.
2) Place dysfunctional joint against its restrictive motion barrier(s) and lock out all other motion.
3) Apply activating force to restrictive motion barriers while maintaining the locking out of other motion. Force is variable! Never “shotgun”.
4) Hold position briefly after the thrust before return to neutral.
5) Re-evaluate joint motion.
What is joint play?
Movement within a synovial joint that is independent of, and cannot be introduced by, voluntary muscle contraction

Essential for normal, pain free, nonrestricted movement of the particular articulation
What are Mennell's ten rules?
Patient must be relaxed.
Therapist must be relaxed. Therapeutic grasp must be painless, firm, and protective.
One joint is mobilized at a time.
One movement in a joint is restored at a time.
In performance of movement, one aspect of joint is moved upon the other, which is stabilized.
Extent of movement is not greater than that assessed in the same joint on opposite unaffected limb.
No forceful or abnormal movement must ever be used.
The manipulative movement is a sharp thrust, with velocity, to result in approximately 1/8” gapping at the joint.
Therapeutic movement occurs when all of the “slack” in the joint has been taken up.
No therapeutic maneuver is done in the presence of joint or bone inflammation or disease (heat, redness, swelling, and so on).
What are the benefits to using soft tissue treatments prior to HVLA?
Reduce hypertonicity

Allow for increased resiliency of tissues surrounding the dysfunctional joint.

Relaxation and reassurance to the patient
What is the goal of localization and why is it important, with regard to HVLA?
Treatment is localized to a single joint.

“Shotgun” to a generalized area of the spine is inappropriate and may be harmful.

Force should never replace skill!!!
Describe Force, within the context of HVLA. How is it applied? What about excessive force?
Applied quickly over a short distance
Motion at joint is only about 1/8”
Excessive force is never a substitute for specificity.
Excess force should not be used in the hope that the joint will move.
What are the indications for force modification (as in using more or less force than typical)?
Pregnancy, guarding, pain, arthritis, elderly, children
What are some causes for that "popping" sound produced by HVLA?
Breaking a vacuum
Gapping the joint
Release of a nitrogen bubble
Electrical discharge
Breaking hydrodynamic fluid
Is that "popping" sound equated with the success of a treatment? Can a treatment be successful without any sound production?
Sounds does not equal success
Sound may be produced from a different joint
Barrier may be overcome without any sound
Sound is harmless as well as necessary
How do patients react to sound from HVLA?
May equate sound with a successful treatment (incorrect)

Some fear that sound means something has broken or fractured (also incorrect, generally)
What are some ways to enhance your HVLA treatment?
Soft tissue technique pre-treatment
Localize restricted joint in all planes
Respiratory cooperation
Redirection of attention of the patient
Mild traction
Double thrust
Post-thrust pause
Adjust the treatment to fit the patient AND your skill level
What are some safety considerations with regards to HVLA?
Accurate diagnosis
Consider possible complications
Ask permission to treat**
Listen with your hands
Emphasize SPECIFICITY
SD with joint restriction is an indication for thrust techniques - not pain
SD often coexist with other diseases so look at whole patient
What are the two major divisions in the cervical spine as far as structure and motion?
Atypical in structure and motion - OA, AA, C1-C2

Typical in structure and motion - Typical motion and structure - C2-C3, through C7-T1
C2-C7/T1 - what are the approximate intersegmental motion characteristics?
Sidebending - less than 10 degrees - C6-T1
Rotation about 8-12 degrees, peak at C3-C5
Flexion/extension - 8-20 degrees, peak at C5-C6
What are the general cervical ranges of motion?
80-90 degrees of rotation to each side
45 degrees lateral flexion on each side
130 degrees total flexion/extension
How does rotation follow the facets?
It moves backwards, upwards, and medial. Anterior rotation is toward the eyes.
What are Luschka or unconvertable joints?
C3-C6 - mid-cervical vertebrae have small lateral joints. They provide stability to the cervical spine by limiting lateral side slip
What is the relation between rotation and sidebending in the cervical spine?
Sidebending and rotation should be in the same direction.
About how much of the weight of the head is supported by the articular facets?
1/3
How does flexion/extension occur in the cervical vertebrae? What kind of sidebending/rotation is associated with each?
Flexion - fix the left facet and flexion of the right facet will lead to left rotation and sidebending

Extension - fix the right facet and extend the left facet leading to left side bending and rotation
What is the primary motion of the atlas on C2?
Rotation
How much total flexion/extension can be found in the A-A joint?
15-22 degrees
What motions can be detected in the A-A joint?
Rotation mostly

Some sidebending may occur but it is also coupled with rotation
If the left facet is fixed, what happens to the right facet?
The right facet flexes and becomes sidebending and rotation left.
What is the most common site of injury in HVLA of the cervical spine?
C1-C2 level - intimal tear with extension and rotation - on the vertebral artery. Especially with too much force.
What are some muscles in the posterior cervical area are important to know?
Rectus capitis posterior minor
Rectus capitis posterior major
Superior oblique muscle of the head
Inferior oblique muscle of the head
Rotatores cervicis - longus, breves
Longissimus capitis
Semispinalis capitis
Splenius capitis, cervicis
What are some muscles in the anterior cervical area that are important to know?
Longus colli muscle
Scalenes muscles (anterior, middle, posterior)
What are some muscles in the lateral cervical area that are important to know?
Sternocleidomastoid
Levator scapulae muscle
MIddle scalene muscle
Anterior scalene muscle
What are some clinical considerations before treating the cervical spine?
Treat the upper T spine and ribs before treating the cervical spine
Check anterior and lateral muscles and fascia for dysfunction
Pain in upper thoracic may be from brachial plexus irritation
Trust intuition and be cautious in face of possible nerve root involvement
Order appropriate tests and/or consults in face of cervical neuropathy and trauma.
What do you do if you suspect nerve root impingement?
Check for motor weakness, sensory deficit, and reflex changes
Where in the cervical spine should one check for sensory changes in the arm?
C5 - anterior middle arm and forearm
C6 - lateral forearm to thumb
C7 - index and middle finger
C8 - medial forearm, 4th and 5th fingers
What nerve innervates the levator and rhomboid muscles? From what spinal nerve(s) does it originate?
Dorsal scapular nerve

C5
What nerve innervates the supraspinatus and infraspinatus muscles? From what spinal nerve(s) does it originate?
Suprascapular nerve

C5 and C6 from the superior trunk of the right brachial plexus
What nerve innervates pectoralis major? From what spinal nerve(s) does it originate?
Lateral pectoral nerve

C5, C6, C7 - from the joining of the superior and middle trunks at the lateral cord of the right brachial plexus
What nerve innervates the biceps and brachealis muscles? From what spinal nerve(s) does it originate?
Musculocutaneous nerve

C4, C5, C6, C7 from one of the terminal branches of the lateral cord in the right brachial plexus
What nerve innervates the teres minor and deltoid muscles? From what spinal nerve(s) does it originate?
Axillary nerve

C5, C6 from one of the terminal branches of the posterior cord in the right brachial plexus
What nerve innervates posterior arm and forearm bracheoradialis, supinator, and triceps muscles? From what spinal nerve(s) does it originate?
Radial nerve

C5, C6, C7, C8, T1 from one of the terminal branches of the posterior cord in the right brachial plexus
What nerve innervates the muscles of the anterior forearm and hand? From what spinal nerve(s) does it originate?
Median nerve

C5, C6, C7, C8, T1 from the combined terminal branches of the posterior and medial cords in the right brachial plexus
What nerve innervates the flexors and intrinsic hand muscles? From what spinal nerve(s) does it originate?
Ulnar nerve

C7, C8, T1 from one of the terminal branches of the medial cord in the right brachial plexus
What nerve innervates the latissimus dorsi muscle? From what spinal nerve(s) does it originate?
Thoracodorsal nerve

C6, C7, C8 from the posterior cord in the right brachial plexus
What nerve innervates the subscapularis and teres minor muscles? From what spinal nerve(s) does it originate?
Subscapular nerve

C5, C6 from the posterior cord of the right brachial plexus
What nerve innervates the pectoralis minor muscle? From what spinal nerve(s) does it originate?
Medial pectoral nerve

C8, T1 from the medial cord of the right brachial plexus.
What nerve innervates the scalenes muscle? From what spinal nerve(s) does it originate?
Long thoracic nerve

C5, C6, C7 - short branches before the nerves become the superior, posterior, and medial trunks of the right brachial plexus
How should one treat the cervical region in a very symptomatic patient?
Avoid HVLA
Treat with indirect methods
Muscle energy applied gently can be appropriate and effective depending on the severity of the problem
Describe the steps in cervical HVLA (per Crotty)
1) Accurate Diagnosis
2) Place segment at the "firm edge" of the barrier
3) Patient rests comfortably in your hands
4) Doctor initiates motion ASAP once reaching the barrier
5) Vector of the thrust determined by whether doing side bending or rotatory thrust
6) Perform a quick thrust through the barrier, from the barrier, no wind-up
7) Re-evaluate
8) Use gentle soft tissue (briefly)
What are some risks associated with cervical HVLA?
#1 risk: stroke - primarily as a result of combining rotation with extension
Where does injury most occur during cervical HVLA? What kind of injury is it?
Tear of the vertebral artery between C1 and C2
What are some things that cervical HVLA injuries had in common?
No diagnosis was listed
No evidence of engagement of barrier
Extension and rotation
What are some absolute contraindications for OA HVLA?
Trisomy 21 (AA is instable, get X-rays)
Spondyloarthropathies (Ra, AS)
Chiari Malformation - type I, generally asymptomatic during childhood, manifests with headaches and cerebellar symptoms
Metastatic cancer, multiple myeloma
Atherosclerosis of the vertebral arteries (or elsewhere - caution)
When is there increased risk of harm in treating a patient with HVLA?
Physician is in a hurry, frustrated
Ignoring red flags
Doing OA-HVLA without "soft-tissue" prep first and last
Substitute strength for precision
Do not localize to the true barrier
Patient is guarded, anxious, tense
Physician not present and mindful
What is the AOA's most recent, official position on cervical OMT (specifically HVLA)?
Benefits exist for headache and neck pain
Harm occurs infrequently
More spontaneous risk of VBA embolization than with manipulation treatments
Provocative tests are unreliable
Risk factors - rotational HVLA implicated
Conclusion: HVLA is effective and relatively safe (compare to NSAIDS, other treatment modalities)
What is the risk of spontaneous rupture of ligament (often transverse ligament of C2) in patients with rheumatoid arthritis?
25%
What percent of patients with trisomy 21 acquire A-A instability? What should be done to evaluate it?
20% acquire A-A instability

Screen for cervical spine flexion and extension views - some recommend annual screenings
Why might some patients not do well with HVLA, even when performed correctly without adverse effects?
The sudden autonomic discharge and reset may be too much for them
What are some contraindications for cervical HVLA besides the big ones of trisomy 21, RA, etc?
Patient does not want or cannot tolerate HVLA
Muscle spasm, exacerbation
Herniated disk with nerve root compromise
Patient does not have head control
Primitive reflexes
Cancer with metastatic risk
Paget's dx, parathyroid problems, fracture
Arterial plaques
Spasticity/contracture
Vascular compromise
Acute condition that may exacerbate (asthma)
Osteoporosis
Hemophilia or anticoagulants
Lens implants or Marfan's/MVPS
Litigious patient
What are the estimated risks from NSAIDs (another treatment for headaches and neck pain)?
10-20% of those hospitalized for GI complications of NSAID use die
1997 estimated death rate from NSAID complications in patients with arthritis was equivalent to deaths from AIDS
Costs from associated GI complications is greater than 2 billion per year
What is/are some good soft tissue treatments to use prior to cervical HVLA?
Cervical long axis kneading and stretching
What is/are some good soft tissue treatments to use after cervical HVLA?
Cervical transverse push pull treatment
What is the diagnostic sequence prior to doing OMT?
Inspection/Observation
Active/Gross motion testing
Palpation
Passive/Segmental motion testing including lateral translation test and rotation test
Neuro-vascular testing
Other considerations?
What should be noted in the inspection/observation diagnostic step?
Check skin for changes in color, lesions, etc.
Look for asymmetry of position and muscular tone
Note changes in AP and lateral curves or weight bearing line
What should be noted in the palpation diagnostic step? Anything specific for cervical region?
Check TART - check anterior, posterior, and lateral muscles as well as upper T spine and ribs
Check patient lying supine - the sub-occipital region, the posterior articular pillar region, as well as areas lateral to the pillars.
Make a segmental diagnosis
What are the cervical gross motion tests?
With patient seated...
Rotate left and right
Side bend left and right
Touch chin to chest (flex)
Look to ceiling (extend)

*Palpate/feel as they perform these motions - have patient perform actively, and physician also tests passive motion*
How do you perform segmental motion testing?
Directed by the findings from TART and the screening exam...
Check side bending, rotation, and flexion/extension
Where may one palpate the transverse processes of the atlas?
In the space between the tip of the mastoid process and the angle of the jaw
Where may one palpate the transverse processes of the axis?
Inferior and posterior medial to the mastoid tip
What muscles are attached to the TP of C1?
Obliquus capitis superior
Obliquus capitis inferior
What muscles are attached to the SP of C1?
Rectus capitis posterior minor
What muscles are attached to the SP of C2?
Rectus capitis posterior major
Obliquus capitis inferior
How is passive/segmental motion testing of the AA performed? What kind of motion is being tested?
Test rotation of the atlas about the axis

Sit at supine patient's head, monitor the lateral masses of the atlas, flex the entire c-spine to isolate other c-spine motion, back off slightly to localize at the A-A
Test Right and Left rotation and note any restriction or difference
How is passive/segmental motion testing of C2-C7 performed?
Lateral translation test done with finger pads on the articular pillars
Test rotation by pressing on articular pillars
Test in neutral, flexed, and extended positions and note/label dysfunctional segments by position of ease
What is the direct, supine HVLA method for AA right rotation?
1) Patient supine, physician at head of table
2) Palms on each side of the patient's head, contact the right lateral mass of the atlas with the MPJ of the right index finger
3) Hold head and flex head and neck fully, and then slightly back off flexion at C1 while maintaining flexion in rest of cervical spine
4) With the MPJ contacting the atlas the physician rotates the AA joint to the restrictive barrier
5) With a quick, short thrust physician rotates C1 left through the barrier
6) Recheck
What is the supine, direct HVLA method for cervical spine C2-C7, rotation and sidebending in the same direction? *Rotation thrust*
1) Support patient's head and neck with arm
2) MCPJ placed on the posterior aspect of the articular pillar
3) Introduce rotation to the barrier with your MCPJ
4) Flex or extend to the barrier
5) Side bend the cervical spine to direction of ease to lock out the other cervical vertebrae
6) With patient relaxed, thrust from the barrier with a quick short impulse through the barrier
7) Place patient in neutral and recheck
What is the supine, direct HVLA method for cervical spine C4-C7, rotation and sidebending in the same direction? *Sidebending thrust*
1) Patient supine, physician at head
2) Physician places MCPJ on lateral margin of restricted articular pillar, and pushes the articular column to induce sidebending and rotation toward restriction
3) Support head and neck for counterforce and rotation
4) Physician flexes or extends the neck as needed to localize to the dysfunctional segment
5) Rotate the spine to ease to lock out the rest of the vertebrae
6) With patient relaxed, from the barrier, thrust with a quick short impulse through the barrier
7) Place patient in neutral and recheck
What may ligamentous instability at the occiput cause?
Chronic headaches
What symptoms may be produced by increased scalene muscle tonus?
Neurovascular symptoms of thoracic outlet syndrome
What is the general zone of innervation in the arm by C5?
The lateral portion of the anterior arm and portions of the shoulder and superior anterior chest
What is the general zone of innervation in the arm by C6?
The lateral edge of the arm and the thumb
What is the general zone of innervation in the arm by C7?
The lateral portion of the posterior arm and portions of the posterior shoulder. Also the 2nd and 3rd digits.
What is the general zone of innervation in the arm by C8?
The medial portion of the posterior arm and portions of the posterior shoulder. Also the 4th and 5th digits.
What is the general zone of innervation in the arm by T1?
The more medial portion of the anterior arm, and portions of the chest inferior to that innervated by C5. Also, portions on the posterior shoulder below those innervated by C8.
What is a sphenobasilar symphysis (SBS) strain pattern?
Alteration of the motion of the SBS that leads to non-physiologic motion of the primary respiratory mechanism
What kind of injury usually causes an SBS strain pattern?
Usually occurs from cranial trauma

May also be manifested through trauma in other parts of the body (particularly the pelvis)
Which cranial bones are affected by SBS strain?
All the cranial bones - both midline as well as pared bones but is referenced to the Sphenoid's relationship to the Occiput
What are the five classical SBS strain patterns? Can more than one be present?
Torsion (Right or Left)
Lateral Strain (Right or Left)
Vertical Strain (Superior or Inferior)
Sidebending Rotations (Right or Left)
Sphenobasilar Symphysis Compression

They can be present individually or in combinations
Does the vault hold produce the same palpatory sensations for different strain patterns?
No, each strain pattern has a unique, identifiable palpable configuration.
About what axis does the Sphenoid bone move?
A single transverse axis
About what axis does the Occiput bone move?
A single transverse axis, just superior to the jugular processes
What cranial bone motions are associated with INHALATION phase?
Flexion of midline bones
Rising of the SBS
External rotation of the pared bones
What is palpated in vault hold during INHALATION phase?
Sphenoid greater wings and Occiput lateral angles progress inferiorly

Temporal bone squamous portions widen anterior-laterally
What cranial bone motions are associated with EXHALATION phase?
Extension of midline bones
Lowering of the SBS
Internal rotation of the pared bones
What is palpated in the vault hold during EXHALATION phase?
Sphenoid greater wings and Occiput lateral angles move superiorly

Temporal bone squamous portions narrow posterior-medially
About what axis do the Sphenoid and Occiput rotate when there is a cranial torsion strain pattern?
Primarily a single anterior-posterior axis
How do you name a cranial torsion?
By the most superior sphenoid base and the greater wing
How does the palpatory experience translate a cranial torsion?
Digits 2 and 5 of one hand move in the opposite (superior or inferior) direction relative to Digits 2 and 5 of the other hand
What kind of injury usually causes a cranial torsion?
Usually an inferior or superior force vector directed on the outer anterior or posterior quadrant of the cranium
In a left cranial torsion, which hand will higher than the other?
Specifically digits 2 and 5 will be superior on the left side
About what axes do the Sphenoid and Occiput rotate when there is a cranial vertical strain pattern?
Two transverse axes - one through the body of the Sphenoid, and another superior and posterior to the jugular processes of the occiput
How is a vertical strain pattern named?
It is named for the most superior sphenoid base
How is a vertical strain pattern palpated in vault hold?
The #2 digits on both hands move superior or inferior relative to the #5 digits on both hands.
How is a vertical strain pattern caused?
Usually an inferior or superior force vector directed along the midline either at the anterior or posterior aspects of the cranium
In vertical strains, what direction do the Sphenoid and Occiput rotate relative to one another?
They both rotate in the same direction (dysfunctional motion - should be opposite motion)
In cranial sidebending rotations (L,R), about what axes do the Sphenoid and Occiput rotate?
Two superior-inferior axes, through the sphenoid body and foramen magnum
One anterior-posterior axis through the body of the sphenoid, basion, and opisthion
How is a cranial sidebending rotation named?
It is named by the side of cranial convexity - so which ever one bulges out the most (essentially named opposite of sidebending)
What is palpable in the vault hold for a cranial sidebending rotation?
Digits 2 and 5 on one hand move apart (concave side), while digits 2 and 5 on the other hand move together (the convex side)
How does a cranial sidebending rotation strain get created?
Usually a lateral force vector directed at the level of and perpendicular to the sphenobasilar symphysis (SBS).
In a lateral cranial strain (L,R), about what axes do the Sphenoid and Occiput move?
Two superior-inferior axes through the sphenoid body and the foramen magnum
How is a lateral cranial strain palplated when in the vault hold?
Defined by bilateral digits #2 moving in opposite left or right directions relative to bilateral digits #5.
How does a lateral cranial strain pattern get created?
A lateral force vector directed at either the left or right anterior or left or right posterior lateral quadrants of the cranium
Describe the SBS compression strain pattern. How would it feel when palpated?
Absence of primary respiratory mechanism flexion and extension.
A hard dense amorphous mass with complete absence of perceived cranial motion (bowling ball)
An abnormal increase in cranial motion or alternating strain patterns, such as lateral or torsion strains
How would an SBS compression strain pattern be caused?
A force vector applied either to the anterior or posterior midline aspects of the cranium, directed through the SBS