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145 Cards in this Set
- Front
- Back
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1. Facts and characteristics of thoracic spine
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1. Limited mobility
2. Upper and middle equal greatest rotation, sidebending is constant, and flexion is greater than extension 3. Lower = flexion and extension; sidebending is greater than rotation 4. Kyphotic curve -> primary curve |
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2. Vertebral body of thoracic spine
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Transverse and AP diameter almost equal
Higher posterior than anterior body (generates kyphotic curve) Spinous process faces posterior and inferior Transverse process faces laterally and slightly posterior |
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3. Articular facets of thoracic spine
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Lined with cartilage, superior facet faces backward, upward, and lateral
Inferior facet faces forward, downward, and medial Costal articular facets in all thoracic vertebra except for T12 |
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4. Spinous process rules of three
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T1-T3: spinous process in same plane as transverse
T4-T6: spinous process 1/2 way between its own transverse process and the process below T7-T9: spinous process in same plane as lower transverse process T10-T12: gradual regression until T12 is in the same plane as its own transverse process |
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5. Splenius captitis and cervicis (upper thoracics only)
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Splenius capitis and cervicis
Origin: T1-T6 Insertion: cervical spine and nuchal line on head Function: control sidebending and rotation of the head Thoracic dysfunction = head function |
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6. Internal and external obliques
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Trunk rotators attached to lower ribs and dysfunction affects diaphragm.
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7. Erector spinae
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Extends and sidebends trunk
Type I dysfunctions |
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8. Multifidus
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They are inter transverse muscles involved in viscerosomatic and somatovisceral reflexes
Mostly type II dysfunctions |
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9. Neurology of the thoracics
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Sympathetic T1-T4 are for the head and neck
T1-T6 are the heart and lung T5-T9 are the stomach, duodenum, liver, gallbladder, pancreas and spleen T10-T11 are jejunum, ileum, kidney ureters, gonads, and right colon T12-L1 are left colon and pelvic organs |
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10. Thoracic spinal motion
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Extension = least motion; limited by articular and spinous processes
Flexion = second least motion; limited by interspinous and posterior longitudinal ligaments and ligamentum flavum. Sidebending (lateral flexion) = second greatest motion; sidebending of group to one side and rotation to the opposite Rotation = greatest motion; axis at the center of the body |
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11. Taking history of thoracic dysfunction
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History: very important for narrowing down the cause of the problem
Location, duration, stress, quality, radiation, relief/aggravation |
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12. Observation of thoracic spinal region
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Skin = redness and palpation
Relationship of the neck to the midline Sternum (pectus excavatum/carinatum) Clavicular head levels Shoulders - excessive rounding Nipple height |
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13. Examination of the thoracic spinal region
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T2 – sternal notch;
T3- scapular spine; T4 – sternal angle; T7 – inferior angle of scapula; T9 – xiphosternal angle Finding of T1 using C7 |
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14. Palpation of thoracic spine
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Using pads of fingers (superficial to deep)
⁻look for red reflex (run fingers along both articular pillars, see if redness lingers in one location longer than another); sign of acute problem ⁻diagnose type 1/type 2 dysfunctions using previously taught methods (i.e. posterior transverse process, etc) *make sure patient’s head is in neutral (not looking to one side) |
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15. Motion testing
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Active: checks muscle action and range of motion
Passive: checks bones and joints (closer stabilizing hand is to base of neck, smaller region of spine tested) |
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16. Assessment and treatment of thoracic spine
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Develop an osteopathic plan; treat medically if indicated.
A complete plan is medical, surgical and manipulative |
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17. Side bending motion testing
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Base of neck: tests motion of T1 through T4
Mid-clavicle: tests motion of T1 through T8 Acromion process: tests motion of T1 through T12 |
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18. The importance of relaxation
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1. Important to function optimally
2. To have an energy balance between body and mind 3. To relax it is necessary to remove tension 4. Relaxation exercises are a method of self regulation - becoming aware of what relaxed muscles feel like and then engaging a process to replicate the relaxed state |
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19. Benefits of relaxation
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1. Restorative energy
2. Decreased distressing reactions 3. Creates a receptive mental/physical state 4. Prepares the body and mind for activity |
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20. Functional relaxation
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Relaxation exercises useful in certain disorders to decrease intensity of discomfort.
Sometimes able to reduce the amt of meds prescribed and increase the quality of life. Can help with: 1. Phobias 2. Panic attacks 3. Insomnia 4. Hyperactivity/ADHD 5. Chronic tension headaches |
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21. Autogenic relaxation
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In 1930's, J H Schultz indicated in his work w/patients suggested that when they are relaxed, they used two words to describe muscular relaxation:
The feeling of warmth and the feeling of heaviness The more efficient and current terms are quiet and relaxed. |
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22. Method of generating autogenic relaxation
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1. Lie comfortably
2. Focus on breathing 3. Imagine in closed eyelids muscles feeling warm and heavy 4. Sequence of events is not important |
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23. Progressive muscle relaxation
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Systematic method to relax major muscle groups
Process is to briefly flex and then slowly release muscles Can begin w/facial muscles and then continue downward through the body. At end of exercise, breathing is then concentrated with deep, slow breaths while mentally recording what it feels like to relax. |
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24. Jacobsonian relaxation
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Method of progressive muscle relaxation developed by Edmund Jacobson in 1929.
The method is contraction and relaxation of muscle groups. Tense each muscle group as tightly as possible and hold for a few secs and then let them go limp. At end of session, focus on the difference between feeling tense and feeling relaxed. |
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25. Fantasy
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Design a place you may have been to or someday would like to go OR imagine a fantasy that exists only to you...
Centrally be present with the fantasy, rehearsal is VERY important. |
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26. Meditation
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The definition: focusing the mind and paying attention; a tool that allows you to listen to the music and thoughts of your inner self.
A wakeful, hypometabolic state. |
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27. Types of meditation
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1. Concentrative techniques
-focusing attention on a single unchanging or repetitive stimulus such as sound, breathing, or a focal point 2. Non-concentrative techniques -expand attention to include non-judgmental observation of mental activities or thoughts |
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28. Forms of meditation
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1. Transcendental meditation
2. Zen meditation 3. Mindfulness meditation AKA walking/driving meditation 4. Clinically standardized meditation 5. Respiratory one method -developed by Benson 6. Yoga/tai chi and jogging 7. Many more! |
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29. Mantra
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A sound or phrase that is repeated verbally or silently that focuses the mind and allows one to enter into and remain in a meditative state.
Includes sacred sound, chant, word, and prayer |
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30. Physiological effects of meditation
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1. Decreases sympathetic activity
-HR, Resp, O2 consumption, plasma cortisol 2. Increases alpha (8-14 Hz) and theta (5-7 Hz) brain wave activity; decreases beta (15-25 Hz) 3. Decreases blood lactacte (stress) 4. Increases DHEA-S |
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31. Benefits of meditation
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1. Elicits relaxation response
2. Decreases effects of stress and helps cope with it 3. Balances ANS 4. Decreases pain 5. Decreases BP 6. Improved mood disorders 7. Reduces use of addictive substances 8. Improves, cognition, intuition, and develops a deeper understanding of self in a spiritual nature |
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32. Basics steps to meditation
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1. Sit up straight, close eyes, relax
2. Breathe in and out slowly, being aware of breath (use abdominal breathing) 3. As you breathe in and out allow yourself to release any thoughts of stress, cares, and conflict 4. Withdrawal your attention from senses as you continue to breath 5. Allow yourself to enter a state of relaxation with each breath 6. Continue to focus on breathing, if mind wanders, bring focus back to breathing 7. Breathing will bring you into a state of meditation, stay there as long as you want 8. Slowly return consciousness back to room 9. Open your eyes |
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33. Self esteem
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A measure of the sense of self worth based on perceived successes and achievements and the perception of the value from significant others
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34. Primary self esteem
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Positive physical appearance and high value
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35. Secondary self esteem
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Achievements and abilities
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36. Ramifications of low self esteem
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Can create anxiety, stress, loneliness, and increase the likelihood of depression.
Can impair academic and job performance. Can lead to underachievement and increase vulnerability to drug and alcohol abuse. |
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37. Improving self esteem (challenging automatic negative self talk)
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Challenging automatic negative self talk which is being overly self critical and not being able to accept praise, overgeneralization, looking glass self (projecting self opinions onto others as if they themselves are thinking it), and catatrophizing.
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38. Improving self esteem (taking care of you)
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ADL's (Activity of daily living)
Get enough rest, eat right, and exercise; have a social life, reward yourself, be cognizant of strengths and accomplishments; be human, don't expect superhuman achievements. |
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39. Improving self esteem (use all existing resources)
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Seek assistance when needed from mechanics, lawyers, dentists, contractors, and counselors.
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40. Self disclosure
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Sharing self information creates a relational fabric.
Disclosing involves risks and vulnerabilities. These include: 1. known to self and others 2. known to self hidden from others 3. blind to self seen by others 4. unknown to self and to others |
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41. Love and relationships
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Assigning values to love of different things
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42. Conflict management
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Conflict can be harmful to a relationship but not all conflict is harmful to a relationship.
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43. Harmful conflict
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Double standards, manipulating others, economic inequities, name-calling and abuse (all kinds)
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44. Healthy conflict
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To care enough to sacrifice tranquility to raise and find problem solutions rather than to avoid problems and allow these problems to infect the relationship.
Can be a motivational tool to get others to be involved and participate. Validate the power of differences between people rather than avoid them |
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45. Win-win situations in relationships
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Work through a cooperative process; requires time and trust
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46. Compromise in relationships
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Serves the common good; everyone preserves something
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47. Lose-win in a relationship
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Appeases and downplays conflict; discretion is the better part of valor.
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48. Win-lose in a relationship
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When the ends justify the means, winning is necessary and these instances may lead to retaliation.
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49. No winners and no losers in a relationship
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Winning is not a priority, the relationship means more
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50. Physician patient relationship
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Leads to decreased patient anxiety, improved syptoms resolution, clear information by physicians, mutally argreed upon goals, active patient role
Positive effect/empathy/support from the physician |
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51. Effect of physician patient relationship and malpractice
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Effective communication is associated w/ reduced risk of malpractice lawsuits
Comparing physicians w/ and w/o claims- Those without claims: 1. Educated patients more about what to expect from the flow of the visit 2. Laughed and used humor more 3. Tended to solicit patients opinions more, checked understanding, and encouraged patients to talk 4. Spent slightly longer in routine visits |
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52. Three classifications of rib motion
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1. Pump handle (1-5)
2. Bucket handle (6-10) 3. Caliper (11-12) |
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53. Pump handle motion
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Predominantly increases the AP chest diameter
Best palpated at the mid-clavicular line. With inhalation, the posterior angle moves inferiorly and the anterior ends move superiorly around the transverse axis |
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54. Bucket-handle motion
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Ribs 6 - 10 move like the handle of a bucket, increasing the transverse chest diameter and occurs around the A/P axis.
The intercostal space widens during inhalation, and the rib moves lateral and superior. The intercostal space narrows with exhalation, and the rib moves medial and inferior. It is best palpated at the mid-axillary line. |
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55. Caliper motion
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Ribs 11-12 causes minimal changes in thoracic diameters.
They move posteriorly, laterally and slightly superior upon inhalation. Dotted lines in figure below show exhalation |
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56. Inhalation Dysfunction (Exhalation Restriction)
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The rib or a group of ribs will be "stuck up,” i.e. unable to move down in exhalation. If it is stuck in inhalation, the rib space above is going to be narrow and below wider.
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57. Exhalation Dysfunction (Inhalation Restriction)
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The rib or a group of ribs will be "stuck down," i.e. unable to move up in inspiration.
If it is stuck in exhalation, the rib space above is going to be wider and below narrower. |
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58. "Key" Rib
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In Inhalation Dysfunctions, it is the lowest rib in the group.
In Exhalation Dysfunctions, it is the uppermost rib in the group. |
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59. Ribs 1 & 2
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Anterior & middle scalenes attach to rib 1
Posterior scalene attaches to rib 2 |
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60. Ribs 3-5
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Attached to pec minor
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61. Ribs 6-8
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Seratus anterior
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62. Ribs 9-11
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Latissimus dorsi
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63. Rib 12
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Quadratus lumborum
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64. Anterior Scalene Muscle
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Origin -Transverse processes C3 to C6
Insertion -Scalene tubercle, superior surface of the 1st rib Action -Elevates 1st rib -Flexes laterally and rotates the neck Innervation -Ventral rami C4-C6 |
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65. Middle Scalene Muscle
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Origin -transverse processes C1 to C6
Insertion -superior surface of the 1st rib posterior to the subclavian artery Action -Elevates 1st rib during forced inspiration -Flexes the neck laterally Innervation -Ventral rami C3-C8 |
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66. Posterior Scalene Muscle
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Origin -Transverse processes C4 to C6
Insertion -2nd rib Action -Elevates 2nd rib during forced inspiration -Flexes the neck laterally Innervation -Ventral rami C6-C8 |
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67. Pectoralis Minor
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Origin -Anterior surface of ribs 3-5
Insertion -Coracoid process of the scapula Action -Stabilizes scapula by drawing it inferiorly and anteriorly against the thoracic wall. Innervation -Medial pectoral nerve (C8,T1) |
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68. Serratus Anterior
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Origin -Anterior surface of the medial border of the scapula
Insertion -Superior lateral surface of rib’s 2-8 Action -Protracts the scapula and holds it against the thoracic wall Innervation -Long thoracic nerve (C5-C7) |
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69. Latissimus Dorsi
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Origin -Spinous processes of T7-S3
-Thoracolumbar fascia -Inferior angle of the scapula -Ribs 9-12 -Iliac crest Insertion -Bicipital Groove on the humerus Action -Extends, adducts and medially rotates the humerus Innervation -Thoracodorsal nerve (C6-C8) |
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70. Quadratus Lumborum
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Origin -Iliac crest
-iliolumbar ligament Insertion -Inferior aspect of the 12th rib and the transverse processes of L1-L4 Action -Extends and laterally flexes the vertebral column -Fixes the 12th rib during inhalation Innervation -Ventral Branches of T12-L4 |
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71. What is the scope of acupuncture?
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1. Promotion of health, well-being
2. Prevention of illness 3. Treatment of medical conditions 4. Body-Mind-Spirit |
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72. Moxibustion
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Moxibustion is an oriental medicine therapy utilizing moxa, or mugwort herb.
It plays an important role in the traditional medical systems of China, Japan, Korea, Vietnam, Tibet, and Mongolia. Suppliers usually age the mugwort and grind it up to a fluff; practitioners burn the fluff or process it further into a stick that resembles a (non-smokable) cigar. They can use it indirectly, with acupuncture needles, or sometimes burn it on a patient's skin. |
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73. What is moxibustion used for?
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Practitioners use moxa to warm regions and acupuncture points with the intention of stimulating circulation through the points and inducing a smoother flow of blood and qi.
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74. Tui Na
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Tui Na is a form of Chinese manipulative therapy often used in conjunction with acupuncture, moxibustion, fire cupping, Chinese herbalism, tai chi and qigong.
Tui na is a hands-on-body treatment using acupressure that is a modality of Chinese medicine whose purpose is to bring the body into balance. The practitioner may brush, knead, roll/press and rub the areas between each of the joints (known as the eight gates) to open the body's defensive (wei) chi and get the energy moving in both the meridians and the muscles. |
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75. Auriculotherapy in acupuncture
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Auriculotherapy, or auricular therapy, or ear acupuncture, or auriculoacupuncture is a form of alternative medicine based on the idea that the ear is a microsystem with the entire body represented on the auricle, the outer portion of the ear.
Ailments of the entire body are assumed to be treatable by stimulation of the surface of the ear exclusively. The body is thought to be represented as an upside-down fetus within the womb on the auricle. |
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76. How far is the needle inserted in acupuncture?
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Acupuncture points are located near or on the surface of the skin.
Usually needles are inserted from 1/4 to 1 inch in depth. Depth of insertion will depend on nature of the condition being treated, the patients' size, age, and constitution, and upon the acupuncturists' style or school. |
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77. Are the needles ever inserted any deeper than 1 inch?
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Yes. For instance; there is a great acupuncture point for sciatica that is located on the buttocks. The needle is usually inserted three to four inches.
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78. Electroacupuncture
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Electroacupuncture is a form of acupuncture in which pairs of acupuncture needles are attached to a device that generates continuous electric pulses between them. Another term is Percutaneous Electrical Nerve Stimulation (PENS).
According to some acupuncturists, this practice augments the use of regular acupuncture, can restore health and well-being, and is particularly good for treating pain. |
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79. Low Frequency (1-8 Hz) electrostimulation
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Takes longer to work, but the results are longer lasting
Great at releasing endogenous endorphins to help relieve pain. Endorphin (H-Pit) Midbrain Spinal Cord Slow onset Long duration Cumulative |
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80. High Frequency (50-200 Hz)
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Midbrain
Spinal Cord Fast onset Short duration Non-cumulative |
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81. Dense disperse waves
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This type of electrical stimulation is most commonly used to prevent sensory adaptation.
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82. What are the five elements?
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1. Wood
2. Fire 3. Earth 4. Metal 5. Water |
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83. Five elements model of chinese medicine
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The interdependence of Zang Fu networks in the body was noted to be a circle of five things, and so mapped by the Chinese doctors onto the five phases.
For instance, the Liver (Wood phase) is said to be the "mother" of the heart (Fire phase), and the Kidneys (Water phase) the mother of the Liver. The key observation was things like kidney deficiency affecting the function of the liver. In this case, the "mother" is weak, and cannot support the child. However, the Kidneys control the heart along the Ke cycle, so the Kidneys are said to restrain the heart. Many of these interactions can nowadays be linked to known physiological pathways (such as Kidney pH affecting heart activity). |
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84. Wood organs
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Yin: liver
Yang: gallbladder |
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85. Fire organs
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Yin: heart/pericardium
Yang: small intestine |
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86. Earth organs
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Yin: spleen/pancreas
Yang: stomach |
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87. Metal organs
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Yin: lungs
Yang: large intestine |
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88. Water organs
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Yin: kidney
Yang: urinary bladder |
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89. Acupuncture Repertoire
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1. Neuroanatomical
2. TCM 3. 5 Elements 4. n-n+1 5. Curious Meridians 6. Electroacupuncture (PENS) |
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90. What are the three disturbances of qi that one can have?
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1. Deficiency (yin)
2. Excess (yang) 3. Blockage = Stagnant Qi |
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91. What are some yin deficiency conditions?
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Yin conditions
--------------------- Degenerative illnesses Diseases of old age (chronic) Depression Osteoarthritis Sx: pallor, hypotonia, dull pains |
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92. What are some yang excess conditions?
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Yang conditions
---------------------- Inflammatory diseases Infections Anxiety Rheumatoid arthritis Clusters, migraines Sx: flushing, agitation, sharp shooting or cramp-like pains |
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93. What are some stagnant qi conditions?
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Myalgias
Muscle spasms with pain Restrictions in movement Muscle tension headaches Tennis elbow Overuse syndromes Myofascial pain syndromes Sx: local pain, venous stasis, congestion, constipation |
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94. Climatic factors
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WIND (feng) – Yang; migratory
COLD – Yin; decreased activity HEAT (fire) – Yang; fever, inflammation DAMPNESS – Yin; heaviness, lingering DRYNESS – Yang; dehydration, dry |
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95. What are the indications for acupuncture with regards to pain?
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Peripheral Neuropathy
Radiculopathy Sciatica Spinal Stenosis RSD Acute Chronic Spinal (C,T,L-S) Myositis/MPS Fibromyalgia Strains/Sprains Arthritis (OA, RA) Tendonitis Post-surgical Cancer Overuse Syndromes Carpal Tunnel Thoracic Outlet Headaches Muscle tension Migraines Clusters Sinus Somatic Dysfunctions |
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96. What are the indications for acupuncture with regards to neuro/psych conditions?
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MS
Stroke Rehab. Parkinson’s Tinnitus Insomnia Depression Anxiety ADD/ADHD |
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97. What are the indications for acupuncture with regards to respiratory conditions?
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Sinusitis
Allergies Sore throats / URI Cough Asthma COPD Bronchitis Pneumonia |
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98. What are the indications for acupuncture with regards to GI conditions?
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GERD
PUD Heartburn Constipation Diarrhea IBS Nausea Abdominal Pain Hemorrhoids |
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99. What are the indications for acupuncture with regards to genitourinary conditions?
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Urinary Incontinence
Spastic Bladder UTI Kidney stones |
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100. What are the indications for acupuncture with regards to OB/GYN conditions?
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PMS
Menopausal Sx Menstrual Difficulties Pelvic pain Endometriosis Infertility Turning breech babies |
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101. What are the indications for acupuncture with regards to cardiovascular & other conditions?
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Hypertension
Angina Arrhythmias Skin Disorders Spiritual |
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102. What are the four contraindications in acupuncture?
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1. Needle phobia
2. Bleeding disorders (hemophilia) 3. Young children (relative) 4. Pregnancy (relative) |
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103. What are the five principles of yin/yang?
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1. Everything has both a yin and yang aspect
2. Subdivides further into yin and yang 3. Mutually create one another 4. Control each other 5. Transform into each other |
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104. What are the four concepts/theories of yin/yang?
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1. All things are part of the whole
2. No entity can be isolated from its relationship to another entity 3. No absolutes 4. Opposition and change (polarity) |
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105. Acupuncture and OMM
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Can be used synergistically for the treatment of pain and other problems:
-Body -Mind -Spirit Can reduce or eliminate Rx’s Often more cost effective than conventional therapies |
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106. Does Insurance Pay for Acupuncture?
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YES – PA Workers Comp./Auto
YES – Some private insurances NO – Medicare/Medicaid/PA Access NO- Most HMO/PPO/Managed Care |
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107. Wu Wei
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No action out of harmony with Nature
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108. What is the order of sequencing in the upper part of the body?
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UPPER
1. (Cranial) 2. Cervical 3. Thoracic 4. Ribs 5. Upper Extremity |
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109. What is the order of sequencing in the lower part of the body?
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LOWER
1. Lumbar 2. Pelvis 3. Sacrum 4. Lower Extremity |
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110. Unilateral vertical band in the parascapular area
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T1-T2: top of scapula refers to shoulder
T3: spine of scapula refers to elbow T7: inferior angle of scapula refers to hand/wrist |
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111. Unilateral vertical band in the paralumbar area
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L1: hip
L3-L4: knee L5: ankle S1-S3: foot |
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112. Screening and treatment order of the pelvis/sacrum
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Screen/treat:
1. Innominate shear 2. Pubic shear 3. Sacral torsion/flexion/extension 4. Innonimate rotation |
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113. + Standing flexion test
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Points to iliosacral dysfunction
Use seated screen to check innominates/lower extremities and treat accordingly |
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114. + Seated flexion test
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Points to sacroiliac or lumbar dysfunction
Use seated screen to determine if the problem is more a sacroiliac or lumbar dysfunction *If sacroiliac problem is greater than lumbar, this points to sacrum *If lumbar problem is greater than sacroiliac, this points to L1-L5 |
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115. What do you evaluate before treatment?
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Extensive History
Mechanism of injury Previous trauma/pre-existing conditions Length of time the pain has been present Pain Scale Aggravating factors Alleviating factors PMH PSH MEDS ROM Neurological examination Special tests relevant to the body region THOROUGH osteopathic examination! Sequencing! TART changes |
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116. Testing L4 nerve root
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Motor weakness in extension of quads
Test with squat and rise Reflex: patella reflex |
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117. Testing L5 nerve root
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Motor weakness in dorsiflexion of great toe and foot.
Test with heel walking No reflexes |
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118. Testing S1 nerve root
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Motor weakness on plantar flexion of great toe and foot
Test with walking on toes Reflex: Achilles reflex |
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119. Deep tendon reflexes
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0-4 out of 4
0/4: absent/ LMN 1/4: diminished/ normal or LMN 2/4: normal 3/4: brisk with unsustained clonus/ normal or UMN 4/4: brisk with sustained clonus/ UMN |
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120. L1-S1 testing
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L1: iliopsoas
L2: Iliopsoas/adductors/quads L3: adductors/quads L4: anterior tibialis - patella reflex L5: ext hallicus longus/quads S1: peroneus longus/brevis/gastrocs - Achilles reflex |
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121. IF + STAND FT (or ST>SEAT)
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Screen:
Iliac crest ASIS Pubes Lower ext |
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122. IF + SEAT FT (or SEAT>ST)
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Re-Screen patient seated from L1 down through the SI joints
If Lumbar AGR then dx and tx lumbar If Sacrum ARG then dx and treat sacrum |
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123. Fryette and spinal motion
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Fryette did not write about the cervical area.
Fryette’s rules of spinal motion do not apply in the cervical area. |
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124. Definition 1 of HVLA
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“’Thrust techniques’ are a collection of direct method manipulative treatments that use High-velocity, low-amplitude (HVLA) activation to move a joint that is exhibiting somatic dysfunction through its restrictive barrier so that when the joint resets itself, appropriate physiologic motion is restored.”
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125. Definition 2 of HVLA
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High-velocity, low-amplitude technique (HVLA) is defined by the Educational Council on Osteopathic Principles (ECOP) as “a direct technique which uses high-velocity, low amplitude forces: also called mobilization with impulse treatment.”
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126. History of HVLA
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Chinese railroad workers influence of Still
Records of the techniques of Still Efficient use of time Teaching assistants |
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127. What is the articular pop?
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Several theories listed in DiGiovanni, Nicholas
Cavitation: -Change in synovial fluid to a gaseous state -Vacuum phenomenon Sound is inconsequential -Presence does not ensure successful treatment -Absence does not mean failure of treatment -Recheck is necessary |
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128. Precautions and Contraindications for HVLA
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1. Vertebral basilar thrombosis has been associated with cervical manipulation (including counterstrain technique).
2. Hyperextension seems to be associated 3. Dens dislocation due to rupture or laxity of the transverse ligament of the atlas (associated with RA and congenital deformities) 4. Pathologic fractures from osteoporotic or metastatic bone 5. Excess force may injure fragile tissues 6. Psychological – apprehension on the part of the patient is a relative contraindication |
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129. Other Thrust Techniques
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1. Exaggeration Thrust Technique
-Not taught in USA Colleges of Osteopathic medicine -Thrust away from barrier 2. High velocity, high amplitude or long lever techniques -Not taught in USA Colleges of Osteopathic medicine -Force often directed through more than one joint making it difficult to control the application of the force |
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130. Guidelines for Safety in HVLA #1
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1. Be aware of possible complications
2. Make a diagnosis 3. A palpatory examination is a prerequisite for treatment 4. Listen with your hands and fingers. If it doesn’t feel right, back off and collect more data 5. If the barrier doesn’t feel right, don’t thrust, but select an alternate technique |
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131. Guidelines for Safety in HVLA #2
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6. Emphasize specificity, not force
7. Ask permission to treat 8. If response to treatment does not meet your expectations, reevaluate the patient. 9. Somatic dysfunction with joint restriction is the indication. 10. Somatic dysfunction often coexists with orthopedic disease (spondodylosis, disc degeneration, spondylolysis) 11. Be aware of the total picture |
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132. Indications for HVLA
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Method of specific joint mobilization
Potential patient benefits: 1. Pain reduction 2. Improved freedom of motion 3. Improved biomechanical function 4. Reduction of somatovisceral reflex “Indicated for treatment of motion loss in somatic dysfunction” |
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133. Contraindications for HVLA
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“ordinarily not indicated for treatment of joint restriction due to anatomic/pathologic changes, such as traumatic contracture, advanced degenerative joint disease, or ankylosis”
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134. Classifications of HVLA
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1. Direct method of treatment
2. Requires specific diagnosis of the joint dysfunction before each treatment 3. Set-up: motion is carried in the direction of its restriction to the restrictive barrier in all planes 4. Activation: high-velocity/low-amplitude thrust |
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135. Mechanism of Joint Restriction
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Abnormal muscle activity is usually involved.
Muscles maintain joint restriction Restriction of joint motion: -Joint gets struck the same way an old loose window or drawer may get stuck – in a position that is no longer parallel to the track -Proper force is neither in nor out (the drawer’s major motion) -Proper force is oblique or side force |
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136. Mechanism of Thrust Technique in HVLA
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1. With thrust, there is an immediate change in muscle texture and in quality and quantity of motion
2. Immediate change in neural activity 3. Mechanoreceptor of joint capsule 4. Sudden stretch or change of position of the joint alters the afferent output of these mechanoreceptors, resulting in release of muscle hypertonicity 5. Involves both muscle spindle and Golgi tendon |
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137. End Feel at Restrictive Barrier #1
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Barrier must be engaged for direct technique
Final activating force is a physician force High velocity, low amplitude Figure 56.1 depicts the force necessary to move a joint to the barrier and is a graphic representation of “end feel” As the barrier is engaged, increasing amounts of force are necessary and the distance decreases |
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138. End Feel at Restrictive Barrier #2
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Barrier is not a rigid wall, but restraints in the form of tight muscles and fascia that serve to inhibit further motion
The physician is pulling against restraints rather than pushing against an anatomic structure Barrier involves a three-dimensional matrix, not just one, two or three planes of motion But... |
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139. End Feel at Restrictive Barrier #3
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We define motion in the three cardinal planes of motion:
1. flexion-extension 2. rotation 3. side-bending Need to also consider translatory motion: 1. for-aft translation 2. side-to-side translation 3. compression-distraction translation All of these single motions are combined into a single force vector when executing the technique The barrier should feel solid. If the barrier feels rubbery and indistinct, thrust technique may be ineffective |
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140. Barrier engagement in HVLA
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1. Experienced physicians develop skills to engage the barrier quickly
2. Experienced physicians sense how the tissues are responding to the force being applied and make subtle alterations in the direction of force to effectively engage the barrier in all planes. 3. Novice takes more time by engaging one plane at a time 4. Engaging the barrier with accuracy and confidence is a skill acquired with practice and experience |
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141. Accumulation of Force at Restriction
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With a proper diagnosis, initial positioning engages the barrier
Forces should accumulate at the restricted joint(s) Forces applied from above and below meet at the restricted joint: 1. Counterforce may be resistance from inertia of body mass, resistance of the table or other resistance 2. Specificity of technique is a measure of how accurately the force accumulates at the restriction 3. Force that does not accumulate at the lesion is dissipated through other parts of the body – iatrogenic side effects The greater the specificity, the less force needed and potential for side effects is minimized |
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142. Corrective Force in HVLA
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1. Short quick thrust
2. High velocity (or accelerating) force -Force is applied from the position of the engaged barrier – do not back off first -Tentative low-velocity force are often unsuccessful -Impulse force - Sudden acceleration and deceleration 3. Very short distance (low amplitude) -High amplitude defeats proper localization -High amplitude decreases livelihood of achieving desired effect |
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143. Alternative Forces in HVLA
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Joint may click during setup
-Recheck, as this was likely to have been a correction -Restriction was released by positioning the patient, localizing forces Sometimes, during or after setup, the physician can “tease” the joint with carefully and slowly applied forces |
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144. Improving effectiveness in HVLA
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1. Patient relaxation
-Skilled physician will sense with hands -Exhalation phase of respiration -Extension phase of CRI 2. Distraction – (diversion of the patient’s attention) -Instructions to patient to cross legs, etc -Not an adequate substitute for the physician’s hands transmitting a sense of control, comfort, and confidence May not be effective in a patient who has been hurt in the past |
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145. Dose of HVLA Thrust
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Patient must be allowed time to respond to the treatment
The sicker the patient, the less the dose Older patients respond slower than younger patients Concerns about hypermobility with repeated HVLA (“Osteobation”) |
